ec 1e-z1 · hr 7 13 ense d 15 kc7 date disp verify by initialing order date clerk/ nurse ' recurring medications, dose, frequency =1_0 ion -zvi i\j (-4 i fl d k val t(4,-) pc-3 "tg°

$Page 1: ec 1e-z1 · hr 7 13 ense d 15 kc7 date disp verify by initialing order date clerk/ nurse ' recurring medications, dose, frequency =1_0 ion -zvi i\j (-4 i fl d k val t(4,-) pc-3 "tg°$
CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE LAN ( NON -MEDICATION )

For use of this form, see AR 4 07:

the proponent agency Is the Office of The S goon General. Ma 1 t yr: 2003 VERIFY BY INITIAIJNG aNiMMAig*I% *' , ,40* INITIAL PROP COLUMN FOLLOWING EACH COMPLETION

ORDER DATE

CLERK! NURSE

f RECURRING ACTION, FREQUENCY, TIME

HR DATE COMPLETED

‘ r. " - - - -0111 07-C\C\I di: \(1C1 2" sCiS

iiiiiip

• - i

op i-c) lov\ec 1e-z1,

•

ALLERGIES: IM YES MN NO PRIMARY DIAGNOSIS:

- slp asw Q.up‘sc— / 1 1-CIC3

ADDITIONAL PAGES IN USE: MI YES 11/ NO

PAGE NO' PATIENT IDENTIFICATION:

USE PENCIL.

li - D 8 9 10

E 16 17 18

N 24 01 02 mpnrcun _ 78441

ACTION TIMES CIRCLE ACTION TIMES

11 12 13 14 15

19 20 21 22 23

03 04 05 06 07 mr,a-r."•• *,..0 • ...mi.,. •• ■••,./ ro e,r-r% el. ■ ••• 1,4

DOD-037019

ACLU-RDI 1681 p.1

HR

7 13

ENSE D

15 kc7

DATE DISP

VERIFY BY INITIALING

ORDER DATE

CLERK/ NURSE '

•

RECURRING MEDICATIONS, DOSE, FREQUENCY

=1_0

-Zvi Ion

K i\J (-4 I fl d

Val t(4 ,-) Pc-3 "tg°

IdEMINILIMIMEr

ND% Nov m-,5 Tie/r-t ringlara

Wan 5

INITIAL OPER COLUMN FOLLOWING EACH ADMINISTRATION

ALLERGIES YES El NO PRIMARY DIAGNOSIS:

PATIENT IDENTIFICATION:

111111111bit!

CLINICAL RECORD THEfrAPEUTIC DOCUMENTATIO CARE PLAN (MEDICATIONS)

For use of this form, AR 40-407; the proponent agency Is the Office f The Surgeon General.

ADDITIONAL PAGES IN USE:

YES Q NO

PAGE NO

DISPENSING TIMES

USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06

DA 1 FAFIr/9 4678 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM -23442

DOD-037020

ACLU-RDI 1681 p.2

Verify by Initialing

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. Yr.

Order Date

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES

Date to be Given be

Time to Given Time Given Initials

/VD LO - e-l- ------- Order/ Expir Date

Clerk/ PRN Nurse MEDICATInN, DOSE, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

- TIME/DATE DISPENSED

lilliDe ill I • Cl7bi 523 li 01-

OA ° et,,,. .Ntr-•iLtilitrk .

7\--k-k/

., -e.-rCCDCe4 --- On 1 l ‘`' 017

7ivot,

1 °3° Adv

2")- 3 3 v.,2)

!goo 61464-eti Vi3o 36 '

14 '''

)0,4' visS ittxt-plow

Zt3r) ( trill 06Lit

atis* 11 1414

1 psi 12°

0 ' 0.4, .

Ucl ° pn,1\3 , 11. I - --- (1.4"

... _ ! r a ,ec, -;

-5--------. _prtAJ

7 )

101cdpr) A Sb :,-,ky

0 (e 9-Pi"' f-) nel utS-e___

gen 12 1 '?c) 20 V 0 14tJa 1- ix)

lord Or-

160 Q

x-54rally*:,

•

atAl 4

M 04,r 1S511,K

Nmsiii---iWTW, , csuv

(Q H- P-4---i krtu'lq ►nt,..._. INItosef - po

.y 0 pi, 1-....

'U.S. GPO: 1998-454-110/95216

MEDCOM - 23443

DOD-037021

ACLU-RDI 1681 p.3

TRAUMA FLOWSHEET The proponent is Dept of Surgery

ABDOMEN

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-88; the proponent agency is the Office of The Surgvn General.

REPORT TITLE OTSG APPROVED (Date)

QI Appr 11 Jun 97

TIM IV x

Meds: ❑ UKN None ❑ Yes:

Allergies: ❑ UKN one ❑ Yes:

Tetanus: ji( UKN

LMPI,

M c

PRIMARY SURVEY

hrs

❑ 02 1 /min ❑ C-Spine Immob

❑ Current Last Meal/Fluid Intake

AIRWAY-:

(1Z4atural

ETT

❑ Secretions

Patient 0

0 0

CIRCULATION • • . "....

❑ Labored 'Jnlabored ❑ Absent

TRACHEA: 9tidline ❑ Deviated

CHEST SYMMETRY:

PULSE: 0 Present ❑ Absent

BLEEDING:

HEART TONES: ❑ Clear ❑ Muffled

SKIN: yl(Warn ❑ Cool ❑ Hot

Pink ❑ Pale ❑ Cyanotic ❑

Dry ❑ Moist ❑ Diaphoretic

a a > = <

SECONDARY SURVEY DISABILITY

. AHEART

USE DIAGRAM TO DOCUMENT INJURIES AND PAIN IAB)rasion

(AMPlutation

(AVlulsion

Battle's Signs

(BL)eeding

(B)urn

(D)eformity

(E)cchymosis

(F)oreign Body

0-0ematoma 0 1144

(LAC)eration

(P)uncture (W)ound

(Pain)

(S)eatbeIt (S)ign

(S)tab (W)ound

(GSW) Gun Shot Wound

SPHINCTER TONE:

Ceis.U21.

❑ None

GCS: E

M

V

C-Spine Tenderness:

Pain @

JVD:

PUPILSXLEqual a Fixed ❑ React ❑ Dilated

TM: 0-Clear ❑ Blood

NECK

sO,

CI

CI

a a

Decreased

Wheezes

LUNGS

BREATH SOUNDO:Nat ;ig:Equal ❑ Clear

Absent

Crackles

RHYTHM: ,...ellegular ❑

PULSES: ❑ Central ❑ Peripheral

a a

VASCULAR ASSESSMENT

a a

4.1

per-Soft ❑ Rigid ❑ Non-Tender

Heme + / - Prostate: ❑ WNL ❑ Abnl

❑ Stable ❑ Unstable 0

Blood at meatus/vagina:

❑ Tender:

0

PELVIS .. • • ..

D Dopler RN

PREPARED BY (Signature DEPARTMENT

Continue on reverse DATE

PATIENTS IDENTIFICATION (For typed or written entries give: Name--last, first, middle; grade; date; hospital or medical facility) ❑ HISTORY/PHYSICAL

❑ OTHER EXAMINATION OR EVALUATION

❑ DIAGNOSTIC STUDIES

t-7 TREATMENT

❑ FLOW CHART

❑ OTHER (Specify)

DA , 117A A

MEDCOM - 23444 .

DOD-037022

ACLU-RDI 1681 p.4

DOD-037023

VITAL SIGNS Rectal Temp:- tQc.. , ( 0 ‘ke cc, GCS: TIME BP HR RHY Ri# a0 l FIO 10:6E:

1 &̀ C:)%0. ̀1Cl 1\J

)'• CO/ 01\ \ 141 AP- 03- 1 103/ vgx ocV,

1,20/,2 )27 NVa .,7

c- `)SL co

Al

0 Downgraded

CO- Spontaneous

3 - To Voice

2- To Pain

1 - None

Oriented

4 - Confused

3 - Inapp Words

2 - Incomp Speech

- None

Obeys Commands

5 - Localizes Pain

4 - Withdraws to Pain

3 - Flexion to Pain

2 - Extension to Pain

1 - None

PERFORMEIZBr'

BY:

BY:

NOTES

4041.1_0'- E .ABI r;

OC,EDURI

0 Backboard Removed

GLASGOW COMA SCALE

EBLE RESPONSE

MEDCOM - 23445

ACLU-RDI 1681 p.5

E

S

TDiIE 'PROCEDURE . .

.,,DIEE ,,SITE. RESULTS

. . . ,i ROCEDUREz ,

-..-...,. _ , COOOPMED RY RN

'- -

ET

Intubation

0 Oral

0 Nasal

Teeth

❑ ETCO2 Change

❑ BBS Post Int

0 Post CXR

CT Scan Xtontrast C)CIA

1,7. ead gAbd Velvis

0 C-Spine ❑ T/L Spine tl(hest Gastric

Tube

❑ Oral

❑ Nasal

0 Air 0 Contents

0 Verified 0

Suction: Y N A-Gram Site:

IV ACCESS & FLUIDS ) aop Urinary

n, {Meatus

❑ Supra-Public L

—

A Return (57,0 LI cc a Heme Dip: + -

• Secured

DPL LI Opened CI Closed

ii&--D- CI Grossly: + -

Cell count

Sent@

TIME l GA •i. I■1!,

) N

Y N Chest

Tube #1 L R

0 Air 0 Blood

0 Pleuravac cm

0 Autotranstuser

Y N

,, ..iyiecile4I1Olt .

MEDICATIONS DOSE f-, RTE TIIN DOSE -,,

4'

Chest

Tube #2 L R. .„

•

0 Air ❑ Blood

0 Pleuravac cm

0 Autotransfuser

12 Lead Rhythm: Comments

0

a siT 1 lCoi: ' Q2zit111cch

11

Ewa.

2) - LABS ,,,.. X-RAYS

a

.. 1...... , AMMINEEINE

11,715M7MMINIIIII ❑ D-stick 0 SHct ME _r Chest Initial - MEM

❑ D-stick 0 SHct , 0 Chest Post ET

BLOOD PRODUCTS nirifil

-\...

,,,\ 4....7

CBC CZhem El=1‹topTT

❑ETOH KtiS "45C&C x \,

❑ Chest Post CT

ail ❑ C -Spine

nal Pelvis 0 Tox Screen

1 4JA 0 HCG Mlle \

-COTNER i) \. () 1 .• iN\ lA., r , A „;5,,,

7IyLEA

TRAUMA TEAM AF, RIVAL

mESI11046ED 'f'4K W ..,eM F

VALUABLES & CLOTHING ,I '''' N'.

D Phys None Found

urgeon Given to Patient

.nesth Given to Family ..,

Inventoried and Released to Patient Trust FundINCOD See DA Form 3696

0 Home

Admitted

❑

Other: See Nursing Notes

DISPOSITION X-Ray

RT

Ortho to

Called to

Transferred

td By

\!) ( - Z....

Neuro Report

Chaplain

- .

MEDCOM

Time

23446 — .... . . .

DOD-037024

ACLU-RDI 1681 p.6

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA lot use 01 this form. see AR 40.66: the proponent agency is the Office of the Surgeon General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED aid

Date: —1 PO %) Anesthesia Type (Circle)): Spinal Epidural Drains Airway Time In: (").3 C55 IV Sedation Nerve Block Hemovac

• NG JP

T-tube

Nasal Oral

Trach

Other

Allergies: 13 E—DP1 OR Intake: Crystalloid 2300 Colloid.... •

Pre-op V/S:120All °MR,— OR Output: UOP EBL <50 Procedures: .a.rt:1612Arreol 0 (PrahMeds/Times: ficen±)cfezt2. 6 t •

Pt-Lad fax.2.44417'onire i6Wr of TLS Pre Op Meds

..0 History .....

Time ci

° ..

01M1.

.0

.1 E .

PhO r Pacu Intake

Sa02 El ig co gni F-0 turt iN crc E Tin Solution Amount Site • By 'Infuted

Fi02

Methods WHEERIVAS lig4

•

33%vli 240

111 4 11 220 X-rays: . Labs:

• Post-Anesthesia Recovery, score

200 Criteria ADM 30' D/C Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities

(0) Moves 0 Extremities

AIRWAY A= Ambu BB= Blow-by M =Mask

180

160 Airway (2) Cough, Deep breath

(1) Dyspnea. limited breathing

(0) Apnea

FT = Face Tent RA =RoomAlr NC= Nasal

' 140 V V

V v ir V

V

Blood Pressure (2) SBP =/- 20 of Pre-op (1) SBP 4-29-50 of Pre-op (0) SBP =/- 50 of Pre-op

Cannula

V/S X =A-line BP

120 V

V v

100 * Consaousness

dying (1) Arousable to verbal or pain

•■■•■•••■•••

. =Cuff BP = Pulse

TEMP

. •

(2) Fu lly Awake audible

80 a 6 •

• • • A A A A A ii Color

121 Baseline color & appearance

(1) pale. mottled. jaundiced (0) Cyanotic

S = Skin 0 =Oral

A = Axilla T = Tympanic

60 A A

A

40 Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

R = Rectal

LOS -

C = Cervical I 20 TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for mc.

T - Thoracic L = Lumbar s=sacral

RR HINNBIllpffliqfflInallin T 77, •• Time Patten teaching done; Wound Ca e. Pain Management, Pain (0-10) T. C. 8 DB.. Incentive Spirometer, Comfort Measures LOS Safely: SR up X 2, Falls Precautions. Privacy Maintained

on ewe ao reverse

DATE b(0- GT11 0

DEPARTMENTISERVICKUNIC

-7 pov c)

Mitten entnes give: lest, middle; grade; date; hospital or medical tackle

111111 ikt) -

Name — last. ❑ HISTORY/PHYSICAL



❑ TREATMENT

❑ FLOW CHART

❑ OTHER ormari

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete MARC 62.00

MEDCOM - 23447

DOD-037025

ACLU-RDI 1681 p.7

PACU OUTPUT

Time Discharge Criteria: Dater-1 /00‘) Time: PARS: Bp:135/77 T: HR: 92... RR: i Z SaO2: qv, Pain Level at D/C (0-10):

Output: ZOO

Ambulance

Source Color/Appearance Amount

Intake: kDC>0 Additional Data: Transferred To: let's,/ 2_ Report Given To: Transferred Via: W. Transferred By: Cleared IAW Recove Charge Nurse Signatu

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

1) Lib°

MEDICATIONS Allergies:

Medication & Dosane

Time Route Pain 1-10

I/E By Pain 1.10

NURSING NOTES

OS&D - oau6, o ctufu9;19 • .1 - • '

12et 01 C-ict/ i t km ,(31 q i 5 p-\- drituku3vi2

(11690INA-0 MCA/

NEUROVASCULAR Time Site Range

Of Motion

Sensory P Cap Refill

T C

Adm

0'

36.......,

45'

D

15;

60'

90'

Movement/Sensation: + = present,- = absent Temp:C = C• • W =Warm Pulses: P = Palpable, D =Doppler, A= A Color: C= Cyanotic,

Capillary Refill: B= Brisk, S= Sluggish P= Pale, Pk = Pink

.; CTIONS

Adm 15' 30' 45' 60' 90' D/C Fund. Height

Lochia

P d#

und. Cond.

DRESSINGS

Time Location Type Drainage

Adm k_OIVV in kl.A6-1) 25/ °

30' kiodicra;r1 t . / , ti,oPaboittn he,;11A

70_1(11R_ [Chi 60' KDOCUT0`^ tc 1.

D/C

LI lb - brao.A1,1A fin yv olooce_a .cto r . 2 tkipin A_op ccuak d

du-bp pket +c) -75% . P-€ p tin ek c 12- L 0z.. Th-AA . anza

o2' rk ■ . oz. n 1 Tkr) bo%

0ukf pf c-32Apoiteive, -b v9/006-0

t-r) / ID titc-h . S 11-v\pov; f\S firrike (A) SS

ACLU-RDI 1681 p.8

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this term. see AR 40.66; the proponent agency is the Office of The Suntan General.

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED /Due)

Date: t1)00; Anesthesia Type (Circle)at)• pinal Epidural Drains Airway

Time In: i Ns Iv • - lon Nerve Block Hemovac

• NG

CE) T-tube

Foley

TLS

Nasal

Oral ETT

Tra

her

Allergies: NOVI OR Intake: Crystalloid 9,(N)0 Colloid. ...

Pre-op V/S: lq.1/u2- 101 OR Output: UOP 350 EBL SO Procedures: 1 1,4 nal:11'1-1g Meds/Times: 500.-1 Pit.-1- •

1C15h ou..4' le-1-1- lel . We:L/03A IC :cajt,tin 4.- levee 3vni

Pre Op Meds Histor

Time 4 .--....

,.-,

-, to --

cl -....

,•-3' --. Pacu Intake

Sa02 19

IA

e Ars

g

tirok

,... ,f).

Itly

.. Tin Solution Amount ile • By Infused

Fi02

Methods

240

220 X-rays: . Labs:

Post-Anesthesia Recovery_score

200 Criteria ADM 30• D/C Codes Activit (2) Moves 4 Exlremities (1) Moves 2 Extremities (0) Moves 0 Extremities

AIRWAY A =Ambu

BB = Blow-by

M. Mask

180

160 Ainvay (2) Cough, Deep breath

(1) DY tinkled breathing (0) Apnea

FT = Face

Tent RA= RoomAir

NC = Nasal 140 V

\/ VI

V Blood Pressine (2) SOP =/- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SE =/- 5Ciof Pre-op

Cannula

V/S

X = A-line BP

120

•

100 •

Consciousness (2) Fully Awake. audible

crYilvg (1) Alousable to verbal or pain

..... ■■

■

.. ■■......'

' =Cuff BP

= Pulse

TEMP •

80 e\ A

A I\ A Color 12) Baseline color A appearance (1) pale, mottled, jaundiced (0) Cyanotic

S = Skin

0 = Oral A = Axillary

T =Tympanic

60

40 Circulation (Pads < 5 Years) (2) radial Pulse Palpable (1) Naar/ palpable. not radial (0) Carotid only reliable pulse LOS

R = Rectal

C = Cervical 20 TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for D/C,

T = Thoracic

L =Lumbar

S= Sacral RR l' ialit lb T

Time Patient teaching done; Wound Care. Pain Management,

Pain (0-10) T. C, & DB.. Incentive Spirometer, Comfort Measures

LOS _____ Safety' SR up X 2, Falls Precautions. Privacy Maintained Ilonnnue on reverse)

bL(/ - / DEPARTMENTISERVICEICLINIC

PA CU DATE

0? Nov 03 PAT first. middle: grade: date;

Or yp or WI7 Name —last, hospital or medkal teary!

0 J (j1 •

❑ HISTORYIPHYSICAL • FLOW CHART

❑ OTHER EXAMINATION ■ OTHER amde OR EVALUATION


5 TREATMENT

DA FORM 4700, MAY 78

WAMC OP 173-E, (Revised) I Apr 01 (MCXC-ON)

Previous edition is obtolete irSAPPC 67.00

MEDCOM - 23449

DOD-037027

ACLU-RDI 1681 p.9

PACU OUTPUT

Time Source Color earance Amount

CARDIAC RHYTHM

Time Rhythm Symptomatic?

O N se_ Rhythm Strip Run?

Discharge Criteria: Date: cgt,sev Time: rd-t-RD PARS:1 BP:131 -70kT:i(Yllf 11R: C 'c) RR: I Pain Level at DIC (0-10): --Intake: Output: Additional Data: Transferred To: C Report Given To: Transferred Via: W Transferred By: Cleared IAW Recov oom Charge Nurse Signature:

Sa02:

MEDICATIONS Allergies: Time Pain

1-10 Medication 8 Dnsane

Route Pain 1-10

I/E

12-2.D an A-46614 1U

►g3tP aon oiti_ak ft/ l!-4L t nv) K61)/1 l)


01 Motion


T Color

Adm 12.1 er, —t- —I-- (-1 y2 \/`-) p v., 15' e( -P -.1 13 Vi f t c- 30' --k. --k P 6 v./ p IC_ 45' ...

60'

90'

D/C Mr -1- -V f 105 W W movemenuseaation: + = present.- = absent Temp:C = Cool, W=VVarrn Pulses: P= Palpable, D =Doppler, A =Absent Color: C= Cyanotic,

Capillary Refill: B =Brisk, S = S uggish P= Pale, Pk = Pink

C-SECTIONS

Adm 15' 30" 45' 90' D/C Fund. Height

Lochia ---------' Peripad#

Fuotleelrid.

DRESSINGS Time Location Type Drainage

Adm r I , +. AMU=

- 4 1 k_ • D

illillinlillil IIII

Mill 30' At 60' D/C , I 111 '4 '

NURSING NOTES

recevele (Ye. 5/ itAk

+VI e ,roi•r, . k-4 V z 99

010 poi n er\c3 AkSO4 ka-3ce r94--

WAMC OP 173-E

MEDCOM - 23450 "ram.mme./Imya.■8•4••■•■

DOD-037028

ACLU-RDI 1681 p.10

Pre Op Meds

Time

Sa02

F102

Methods

240

220

200

180

160

140

120

100

80

60

40

20

RR

T Time Pain 0-10 LOS

,C)

ADM 30' DIC

1L0nrirtUe an MOW)

DATE

119

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet 7 Date: 5 iq k`f 0.5 Time In: 1.) Allergies: Pre-op V/S: Procedures:

X-rays:

Criteria Activity (2) Moves 4 Extremities

Moves 2 Extremities (0) Moves 0 Extremities

Airway (2) Cough, Deep breath (1)Dyspnea. limited breathing (0) Apnea

Blood Pressure (2) SBP =1- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =1- 50 of Pre-op

Consciousness (2) Fully Awake, audible

crying (1) Arousable to verbal or pain

Color (2) Baseline color & appearance

(1) pale, mottled, jaundiced (0) Cyanotic

Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable, not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or greater to DIC. otherwise needs anesthesia approval for 0/C.

DEPA ENTISERVICE/CLINIC

Anesthesia Type (Circle)) {gene Spinal Epidural LI-{_A, 1V-Sedation Nerve Block

Colloid

E OR Intake: Crystalloid

Immo OR Output: UOP Imviip um , Meds/Times:

Nit ci

Drains/ Hem9,/ac

JP - pG.

T-t Foley

TLS

Airway Nasal

Trach

Other

Time Solu on A cunt Site By _ fiamintAramr— "sr , Pacu Intake

Labs:

Codes

Post-Anesthesia Recovery score

Patient teaching done; Wound Care, Pain Management, T. C. & DEL. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

lien entries give: Name —last,

, m • de: grade: date; hospital or medical leafy) ❑ HISTORYIPHTSICAL

❑ OTHER EXAMINATION

OR EVALUATION


❑ TREATMENT

❑ FLOW CHART

❑ OTHER /Away/

Histor

•

AIRWAY A = Ambu BB = Blow-by M — Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula

VIS X = A-line BP

= Cuff BP = Pulse

TEMP S = Skin 0= Oral A =Axillary T =Tympanic R =Rectal

LOS C = Cervical T = Thoracic L = Lumbar S = Sacral

ACLU-RDI 1681 p.11

DOD-037030

Time Source Color/A earance mount

MEDCOM WAMC OP 173-E

NEUROVASCULAR Time Site

-

Range Of

Motion


21111.MNIIIIIIr

T Color

Adm

15' wr riumilwas

30'

45'

60'

90'

D/C

Movement/Sensation: + =present,- = absent Temp:C = Cool, W =Warm Pulses: P = Palpable, D= Doppler, A = Absent Color: C= Cyanotic,

Capillary Refill: B= Brisk, S=S uggish P= Pale, Pk = Pink

C-SECTIONS _...-------. Adm 15' 30' 45' 90' D/C

Fund. Height

Lochia ----------

Fund. d.

DRESSINGS

Time - L• . tion Drainage

Adm r r. I I, 1 ,11 ,_ .

30'

60'

D/C

NURSING NOTES

,_...- CARDIAC RHYTHM

Thile Rh thm S mptomatic? Rh thm Strip Run?

;DID

BP: it-4T: ìt Pain Le er it D C 10-101: Intake: Additional Data: Transferred To: (,l)

Report Given To. Transferred Transferred By: Cleared IAW Rec

Signatur - 23452

PARS: RR: / Sa02:ioa

Output

Discharge prq Date:(--,7u

2 MEDICATIONS

Allergies: Medication & Onsaae

Time Route PIE By

z

Pain 1-10

P.' 1-10

PACU OUTPUT

ACLU-RDI 1681 p.12

)

2. MTF Location

Reporting MTF

Admission and ..04D-Aing Information

4 ; Register Number

IL For use of this form, see AK 4U-4uu; me proponent agency is u i ou

Name (Last, First, MI) 4. Pay Grade

F GN

5. Sex

M

6. DoB (YYYYMMDD)

1968-06-01

[

7. Age at Admission

35Y

8. Race

X

9. Ethnicity

9

Religion

. . 10. Length of Service

Organization (Active Duty

ETS

Only)

11. FMP

13. Marital Status

_ ...

L

12. Social Security Number

Hour of Admission

01:00

- Li . . ..

Branch / Corps:

14. Flying Status 15. Beneficiary Category

K78-PRISONER OF WAR/INTERNEES

16. Zip Code of Residence:

17. Unit Location 18. MOS 19. Trauma

DIS

Prey. Admission

NO

20. Source of Admission . Ward: Name / Relationship of Emergency Addressee -

Direct from ER ICW 1 Address of Emergency Addressee

N . .ie and Location of Medical Treatment Facility: 1

b (1 t

Telephone Number of Emergency Addressee

21. Type of Disposition 22. MTF Transferred To

TRF-OTH

23. Date of Disposition (YYYYMMDD)

2003-11-18

24. Clinic Svc - Admitting

GG - FP ORTHOPEDICS

25. MTF Transferred From 26. Date this Admission (YYYYMMDD)

2003-11-07

27. Location of Occurrence 28. MTF of Initial Admission 29. Date of Initial Admission

2003-11-07

FOR LOCAL USE

Type Patient (Inpatient / Outpatient): Inpatient

Admission Diagnosis Narrative: S/P GSW L GROIN R LEG g7V, 1--- is4 se, 5'

0

Cs 7.3.

41/9, 81

Procedure Narrative(s):

Cause of Injury Narrative:

MEDCOM - 23453

DOD-037031

ACLU-RDI 1681 p.13

ETHNIC RELIGION 6. DATE OF BIRTH (Y Y Y YMMD D) 7. AGE AT ADMISSION 8. RACE 9.

BACK-GROUND

19 20 21 22 23 24 25 26 27 28 29

32 34

50 ENO 47 48 ' I • 49 60 61

22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (Y YMMDD)

EN11111311121011311 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION (Y Y MAID D)

90 87

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS •

46 I HOUR OF ADMISSION .

BRANCH / CORPS

14. FLYING STATUS 15. BENEFICIARY CATEGORY

17. UNIT LOCATION (State or 18. MOS Country Code) 62 63.

16. ZIP CODE OF RESIDENCE

5.3 154 I 55 I 56 57 58 I 59

• •

PREY. ADMISSION

YEAR

NO

19. TRAUMA

64 65 66 67 68 69 70 71

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD

72 ADMISSION 1

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

•

_ • - -• ••_ -•

91 " 92 93 94 95 96 97 98 99 100 .101 102

28. MTF OF INITIAL ADMISSION 29. DATE INITIAL.ADMISSION • (YYMMDD)

21. TYPE OF DISPOSITION

24... CLINIC SVC - ADMITTING

27. LOCATION OF OCCURRENCE (Battle Casualty Only)

103 104

OR LOCAL USE

r-t-ttiol c"-)

1

703

A FORM 2985, MAR 89 EDITION OF MAY 79"IS OBSOLETE USAPPCV1.00

MEDCOM - 23454

DOD-037032

ure, as required) DMITTING OFFICER (Sign SIGNATURE OF ADMITTING CLERK

30 31

11. FIMP 12. SOCIAL SECURITY NUMBER

MEND 40 enzuramamm

rt."LJC 1 5. SEX

16 17 18

10. LENGTH OF SERVICE ETS

9 I 10

/

11 I 12 I 13 I 14

•

r

ACLU-RDI 1681 p.14

riProperty/Contraband J weapon Photo Taken of Suspect with Weapon/Contraband: Yes/ No

0 YELLOW FIELDS MUST BE FILLED IN, IF APPLICABLE, UPON APPREHENSION

Ofense against CiviIin(s) [check one] Ff "Other" then de&cribo •:::

:: .. .. .. . . .... . . .

. ....

. , . , • • .... .

eittresq .... ,.....: . . .:

ii;;;;;;Wk4iIi,iii61646k.1“) ,. ,.. . .. ' nurvelI,Q Miiirt ' 01 1r? ..., .: .. '. • •'.

.1..4nc,oMtgryMIs.IQl .t.,:

- . — – -

Date of Report: (D/M/Y) Time of Report:

/ / hrs

1

COALITION PROVISIONAL AUTHORITY FORCES APPREHENSION FORM 0

Place of Birth:

Ethnaribe/ Sex:

Sect:

Type: [Model:

Serial No.: Quantity: Make:

Other Details: \o, - r 1 Where Found:

Color/Caliber Receipt Provided to Owner: Yes/ No

Owner

DOD-037033

ACLU-RDI 1681 p.15

Automated Facsimile I. ATIENT TREATMENT RECORD-- ,vCR SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

1. Register Nbr ' 2. Name 3. Grade FGN

Admission Remarks

‘

4. Sex M

5. Age 24Y

6. Race X

7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm

NO

11. FMP

99 12. SSN 3. Organization

6 ( (-L \ - (4 14. Ward

ICW1

15. FlyStatus 17. Dept / Ben

K78-PRISONER OF WAR/INTER

18. BranchCorps 19. UIC / ZIP 20. Type Cas.

DIS

21. Source of Admission

Direct from ER 22. Hour Of Adm:

03:00 23. Clinic Service AEA - ORTHOPEDICS

24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH

26. Date of Disp

2003-11-13

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:

2003-11-08

. in Officer:

\Th M -1-

29. Re

( 't_ - Z

30. Date Ink Adm

2003-11-08 32. Units Blood Com onents P

31. Selected Administrative Data

Marital Status: DoB: 1979-01-01

In/Out Patient: Inpatient MOS:

33. Cause Of Injury:

34. Diagnosis / Operations and-Special-Procedures:_ „,- _____..

S/P VD R IF DPC OPEN MC FX VD BL LE

/2 - OD V 1

01-616 , 6,2F /

g a a 935/

8)6 ,'6/'

1 D

----.........,,,,,N 2 / _S-- , / 0 qIci. i E9 9 1

1 1 g

-3.Sy / 9

g ca. s- -

..___L., of 9

.

35. Total Days This Facility._ Absent Sick bays

0

Other Days ConLv / Coop Care Days Supplemental Care

0 Bed Days I Total Sick Days

6 I 0 35. Total Days This Facility

s

i

Lt-7

Supplemental'Care

..4 Bed Days Total Sick Days

. .

Absent 'ck Days . ■•

Other Days ConLv / Coop Ca a

Signature of Atte

Automated Facsimile - DA FORM 3647, May 79 MEDCOM -

DOD-037034

ACLU-RDI 1681 p.16

ABBREVIATED MEDICAL RECORD MEDICAL RECORD

-PERTINENT HISTORY. CHIEF CONFLAINT. ANO CONDITION ON }OMISSION ( ft, •bitc .. ,ionJ

2 9 P r 9'05: Ct' 5/Arl f'6.

AilAV

$L_ L s 114Q t)-fz- _ 467,4 Car,

Ott—Apt

PirlYSICAL EXAMINATION

"iAb

bdp - croll kg0-6 ,6\)

zi)*1 P usir,-St cr6ndw.- GwC_ -NAP LT iwi-D, &

tt,d-Ksl-• 7179@ 11A4(52-e

(.61 4 6.4c.,4?1,,,, G2, • A3/4

An1/7 FgOth - D AvT. •

LL 1 1141\3 1.4.-40-9

icu4s. PrgrivN . 10-1-TP, Dal vz.

xy - P rkc. P)- (

flArbya et

PROGRESS Eltrer :ate at dr.TrAnrpe and I •liavouss•

arp ofr irt

a. frort-il- vizu-za

()Li Ca. T4-b7 g-TP-PNL-Pc

re-P us s

t

ORG....NI ZA r10/4

O ATS_ IDENTIFICATION

SIG NA7

,..xd ••••t cren N.rne

Ar.vdo. d•r o6plf•I Of rn,d,..al IACslity)

REGISTER NG. I wAR C

ABBRE'HATED MEDICAL RECORD Standard. For= 339

OE .RAL SER'/;CES AND

:NTEPAGENCY DC,mmITTES ON A_-LICA(.

F.E,,CSDS DF--1)

CC:C.3,7A I375

MEDCOM - 23457

DOD-037035

ACLU-RDI 1681 p.17

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD PROGRESS NOTES

DATE NOTES

c6el\ID193 (152:04 1(2C\ c.x.2_ 6- --v\-- PocNn \COa --f), , \X- .._._ .11-1 ayx-Nno , NOV_S2- CamdC • V, S. li)-- clarS ' —111 Ilk j

P'cic )C--- Ali P cl c) ?a -- . Ws-as .0 2-■.___ _F___. c_,:u

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— )\)e..: • s.c_c-A--(o1 .■c,"-\- (0\--\s , \f\f, ■ \ c \c:, Afdc.' rY1CA-\V-VOi

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A Mj latAW 7S LS /Q3K CV-Lii. Chi CtiCtitrA. ((/YY-1 1 orra

WA' I \ V ah( cU Otut161' Iii-tivr,t -ibk • Wm. tAik uw-ruue .

al 03 A..../__, , , 6.A., • d 4272M-RIPL,z

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A € Az hz(ri. -,, rte zcJA..e,(de; RELATIONSHIP TO SPONSOR SP SOWS NAM SPONSOR'S ID NUMBER

(SSN or Other) LAST FIRST MI

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade)

I REGISTER NO. WARD NO.

2--

PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999

Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10

USAPA V1.00

MEDCOM - 23458

DOD-037036

ACLU-RDI 1681 p.18

LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES

.1' , _ _A _ -, -.A.

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44 ii-tie.i.el, e--,2. 171- ' • 41 - —

4.), AL-

) 6 716ti a.3 il .• ///z,.4‘.- -6 /al- 1, Y Amor/ __„4_ -_,___±4 , / —.maw -4F--

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"QS Y 10 vvri(r...4p, epAll. Pfahl-e-fo iNi. if lq n- rs- . 'Th

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1\00\C . \i'. . CI) C10 ■ . 6 CC-N ,clk-Q---1 d1

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S .q(__->ic. \\(-- ■--\-c-Icx-. --Ax ..:v\-,c-\-

(0 k --- ).1'

C. P\-- --zmu--c-I j( _A1-._o

--i?D 1"C‘-`3) g',<---ir-3e..cs "Dr,s 'irD \e3.E._ C__vk . () CICS ;17tc 0.

ea ..... ... id" s. 4. -- -ou:--- PA- ....•__ • 101.. \-2..._ ----;?--). 2-\-- c-.€=_ .).9cm hr mike_ir

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x, n---ft -t\--) k -y

r\D-/F 6 -fC( -) -tl:2) The...__ -\(:\ Z.. 9c()CR.Q.5--A __,,/--

STANDARD FORM 509 (REV. 5/1999) BAC; USAPA V1.;L

COM - 23459

DOD-037037

ACLU-RDI 1681 p.19

b10 -7-

AUTHORIZED FOR LOCAL REPRODUCTIOt


DATE NOTES

11 Nv...3,1cp?-, (pitDO-PEc-r-s\N26 ( --,--:(-42_ £ lx--itc.1).. Pc <-4o cit- -,spec.— .P\c‘Vic:_ • \iGs c c o yo.,\ i- s ar-z-c,, --\- L% e_, W-ci) c-VF-T

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( CIP) \(\i\jc-i -'S 6\ Cc)1')\

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CA -V-Cc-' k )\ — Cg c. dicoA ci1A- t\-\\-c-,?_36c3 — RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER



PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; I ID No or SSN; Sex; Date of Birth; Rank/Grade)

REGISTER NO. WAR_D NO.

PROGRESS NOTES Medical Record

111111V- MEI - 23460

STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10

USAPA V1.00

DOD-037038

ACLU-RDI 1681 p.20


DATE NOTES

(0 Obv /03 UltMAV W1 EF 0)9006 f 0 bsQ Cg), 4,--Q VF vu-- 5 / L.-. cv7k,61-1,,6 P .17;<- Boal

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USAPA V1.0

ay)

DCOM -23461

DOD-037039

ACLU-RDI 1681 p.21



DATE NOTES

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER



PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN,- Sex; Date of Birth; Rank/Oradel

. 1 \

I REGISTER NO. WARD NO,

1C\Kiil

6 -4

gilli

MEDCOM - 23462


STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101 - 11.203(b)(10

USAPA V1.0C

DOD-037040

ACLU-RDI 1681 p.22



DATE NOTES •

13 ON 03 D 1 scHoLe Sun/161)1R`

Airitii t idd.,‘„.e , (Ail asto -4 1-1,„, 0)-41- Lt44-, cte•I CltappiA,

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,if __marl)

LAST FIRST

DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT kidocifr LI

PATIENT'S IDENTIFICATION: /For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date of Birth; Rank/Grade/

REGISTER NO. WARD NO.


STANDARD FORM 509 (REV. 5/1999: Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)110:

USAPA V1.00

MEDCOM - 23463

DOD-037041

ACLU-RDI 1681 p.23


MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE

DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

1,

(1\11 0-0 03 wif\c) o f o-c-6

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Iv AP ( i.ite tir_ Aisci,f,t i„,,ze,,_ ci_ To _.- 2-X6),

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE RECORDS MAINTAINED AT

SPONSOR'S NAME SN/ID NO. RELATIONSHIP TO SPONSOR

PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; ID No or SSN• Sex; Date of Birth; Rank/Grade.)

REGISTER NO. I WARD NO.

CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 6001REv. 8-971 Prescribed by GSA/ICMR FIRMR 141 CFR) 201-9.202-1

MEDCOM - 23464

DOD-037042

ACLU-RDI 1681 p.24

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT MEDICAL RECORD

FOR Use this form. See AR 40-407: the Proponent agency is The Office of the Surgeon General.

2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) ❑ NKDA RPCN 5 ❑ LATEX ❑ IODINE ❑ TAPE 0 FOOD REACTION:

3. PREVIOUS SURGERY y NO [ YES (type):

1. AGE Z9

HEIGHT:

WEIGHT:

9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)

Ina C -57)

MEDCOM - 23465 F I CVIUUJ CUILIOI i aic UUJIJIGIC.

DA FORM 5179. JUN 91

4. PROPOSED SURGICAL PROCEDURE:

14-r) kowsol

5. ADDITIONAL INFORMATION: (Previous surgical and medical story) Skin Condition zetiwci,'\ 1-1- lAicrs^"^c-A

Tobacco ppd X_vrs Body Piersirgi Diabetes (Y) ( ROM 41 EMve`^^,N5ASA/Motrin W 72hrs (Y)(j ETOH Implants Respiratory Disease (ASthma COPD) (Y) lel Anticoagulants (Y) Glasses/Contact (Y) (N) Dentures Hypertension (Y) 11 Herbal Medicines (Y N) MEDS:

6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS

A. PSYCHOSOCIAL --- potential for anxiety related Pt. verbalizes any specific anxiety.

Pt. Exhibits relaxed body posture.

! , - ‘ ..t..-------,

– q) . i I( .;.< ‘ ,..A.--0.82 ,....."4-v-..e,v

t

0.

stay

. Allow pt. to verbalize freely.

. Explain Or environment and answer

estions regarding surgery.

. Offer comfort measures. (e.g. warm

anket. touch).

. Explain all nursing procedures before

ey are done.

. Remain with pt. VVherrver possible.

Maintainifarnily interfAe. Parents to

with pt.

to:

..---- 1) Surgical Procedure& Operating Room Environment

2) Separation Anxiety

)! (Cy 3) Surgical Outcomes

B. AERATION ----- Potential for respiratory

_.-0—Pt. will be able to breath without

difficulty during immediate intraoperative

phase.

. Offer to elevate head of litter or offer

illow.

. Observe pt. While awaiting surgery for

•gns of distress.

. Assist anesthesia during intubatior

d extubation. 1. -,/

dysfunction due to: ....--

1) Positioning

,"--- 2) Effects of Anesthesia

3) Medical/Smoking_History

C. INTEGUMENT Potential Impairment of Skin

9- Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).

. Utilize pressure preventing devices

OR table and accessories.

. Check for proper positioning and

upped to maintain good body alignment.

. Pad pressure points.

. Place ESU ground pad on non

mpromised skin surface area.

Keep prep fluids form pooling.

Integrity due to: ---- 1) IntraoperativeL-nrnotility

----. 2) ESU Pad Placement

3) Positional Aids

ProstheSiS

----"-4) 5) Pooling_gf Prep Solutions

VERIFICATIONS AT HOLDING AREA: ID/ID/Allergy ../ y Band Dentures Rertil6ved

H&P

! Contacts moved

NPO Since

I Jewel Removed

-E4-1.GGM14172, ! Bo Pierce Removed

Consent/Blood Transfusion Signed/Witnessed/Dated

Surgical Site/Consent verified by

Pt./Anesthesia/Surgeon

Contact precautions (Y)piK

. Family/Friend: ps'..

USAPA v1.0

DOD-037043

ACLU-RDI 1681 p.25

7. PATIENT GOALS AND EXPECTED OUTCOMES

will exhibit signs of adequate tissue

----perfusion (e.g. color, warmth. pedal pulse.

8. OR NURSING INTERVENTIONS

O Check foe support stocking or ace warps. if none, check with doctors.

--45—Cfieck that safety straps are correctly applied. O Offer pillow for under knees.

O Place and take down legs from stirrups with slow bilateral motion.

r0' Check that rings and all body piercing has been removed.

6. PATIENT PROBLEMS AND NEEDS

Potential for inadequate tissue

perfusion due to:

Intraoperative Mobility

2) Positioning

•

45)) 5HaypthfeotyDeremv iiaCes

E. NEUROMUSCULAR

CONTROL Potential Impairment of

Mobility due to:

1) Pain

2) Intra operative Hazzards

4) Positioning

---"" 5) Transfer pt. To/form OR table E.2. --- Potential Discomfort Due to:

CI pt. will be transferred to OR table without gifficultly .

0 pt. will be not experience unnecessary

physical discomfort.

01 Have sufficient people available for trtmsfer. 0 Insure proper body alignment. q Allow patient to lie in position of

comfort while waiting for surgery. Offer support (i,e..pillows. Bath

t wel. etc) for positioning.

1) Length of Surgery

2) Positioning 3) Arthritis

F. Special Senses F.I. Diminished visual perception due to being:

1) pre-medicated

W 0 GLASSES

F.2. ----- Potential for Decreased

Communication due to:

1) Diminished Hearing

2) Language Barrier

F.3. Potential Injury due to

Dentures:

pt. will be made aware of surroundings p for to anesthesia induction.

pt. will be transferred safely to OR table.

Ipt. will be able to understand instructions. Minimize danger of injury during intraop

riod.

01 Introduce self. keep pt informed as to ere he. she is and what is happening.

01 Inform pt. in which direction to move aid assist if necessary.

Speak clearly and slowl . Address pt. from side.

Validate pt.'s understanding of verbal ommunication.

O Verify removal of dentures.

1) Upper 2) Lower

3) Bridges

4) Caps

5) Crowns

G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.

OTHER NURSING INTERVENTIONS OR continuation of above Interventions.

10. OR NURSING INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.

tt-t\J DATE

11. POSTOPERATIVE EVALUA SKIN INTEGRITY: Bovie Pad Site: 12r Clean and Dry ❑ Red ❑ N/A DRESSING DRY & INTACT: ,%

LEVEL OF CONSCIOUSNESS: ❑ A&O L Drowsy ❑ Sleepy 1:1 intubated (N)

LEVEL OF ACTIVITY: lg MOVES ALL EXTREMITIES ❑ Moves Upper Extremities 6

EATHING EASY:

❑ Transferred to Litter With roller due to spinal

12. PREOPERATIVE EV PREPARED BY 13. PREOPERATIVE EVAL (Signature and Tir -- ) 7 cAn- iitiks, BY (Signature and Title) r c)A,

, i k.,.- 2., DATE: aV,\1613 TIME: 0 DATE: g \\JCV1/47 TIME: 09 1-(-5

REVERS OF FORM 5179, JUN 91

MEDCOM - 23466

USAPA VI.0

DOD-037044

ACLU-RDI 1681 p.26

MEDICAL RECORD f INTRAOPERATIvE nOCUMENT For use of this form, see AR 40-407, the prof , ;icy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPERAT 1 iM

VIA ' . Y By 1..\--C.A" 2. PATIENT IDENTII AND PROCEDURE

VERIFIED BY CAVT •.. ( ) -..?-

3. DATE TIME PATIENT IN SUITE

-1K '1‘' sr,X) n 7 4; PATIENT IN ROOM

-2 TIME• ; 0 g 4-0 NUMBER

5. PREOPERATIVE EMOTIONAL STATUS

ANXIOUS EXCITED.

VC\62-CX"

❑ ANGRY a CALM U II CRYING U WITHDRAWN U OTHER (Specify)

COMMENTS: ia (- 01")`"VVI7 _. ...

6. NURSING PERSONNEL

ASSIGNED SCRUB

._-)c;;C, -------- -""` "RELIEF .. .SCRUB

ASSIGNED CIRCULATOR

C TT 1111.11111N RELIEF —....CIRCULATOR

11‘.i .-f. • .

7. POSITION AND POSITIONAL

IN SUPINE

,=-(3,,r \-.2-0 COMMENTS:

AIDS (Specify)

LITHOTOMY , ❑ PRONE ....)/-Ace.A4n.e.2.A.nA . -''"

-•.,- ..-, .

LATERAL: U U KRASKE ,...,:AAckAAA.-A,7nA...ztki

• LEFT SIDE UP • RIGHT SIDE UP

4-=.. 8. SKIN PREPARATION

HAIR REMOVAL 0 YES II NO ' UNIT

-- .

PREP SOLUTION (Specify) C"...1CA-c",,-'--t— ICS•P-Ac\- - s sk SITEcgCs.,-, ‘,...N. BY WHOM: SITE: b‘ LE. BY WHOM:

..... COMMENTS:"1,...(7,' y TN( 9/,,,,1/4„,1/4 /1 ,l

DONE BY: 0. OR • NURSING METHOD: I/ DEPILATORY 0 RAZOR

• CLIP

— COMMENTS:

9. LOCATION OF EXTERNAL

•

.

- .

Pa

DEVICES

..,

s

.7.-N.,..,

-

.

- Safety Strap =

e.,"0...,V 1r611 ki,&& ' . ".""

1--.::-Nrts _ . .

Al' ....

kil..

-

..../ ...

k. 0 \ r

■

....

f • I .

LEGEND X Ground

-.MIMMINA.-4111/1-1111Mal I I raffP Til

= = Tourniquet

-.--

0‘i --. :• -2

10. COUNTS

C = Correct I = Incorrect ( (--c. - 2

Other•' First Closing Count . !,

Final Closing Count • E. __ CIRCULATOR

Sponge 0 Yes

Yes

Vo

o

..

......--"" ..,;-----

,----..-. .. ..-..... . Needle Sharp [2 Instrument ❑ Yes M o :, I. .;. -1 -,". T - . Other NI Yes kNI Vo 11. PATIENT IDENTIFICATION (For typed or written entries give: Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

471)

,

i Q \ik\'iC,3 4' (2-11 '

12. ELECTROSURGERY DEVICE(S) (ESU)

‘kelic.:Ar"

• YES NO .2:1

-t L3Nr u)... Lk() kg ESU NO: VC\

GROUND PAD:

. ; ..0.4ESU NO:

BRAND VL V...;,/-A. ,,\ l'IQVII`rtil- LOT NO -.4" 4 . 5 g "7 4 x .)--s" -

- --GROUND PAD: ' -..-.

• BIPOLAR NO:

BRAND

LOT NO:

-1, LACES DA MEDCOM -23467 -I IS OBSOLETE. USAPA V1.00

DOD-037045

ACLU-RDI 1681 p.27

13. PROSTHESIS, IMPLANTS • YE._ ' NO IF YES NAME: ID NUMBER; ÔTURER

'MEDICATIONS/ORDERSM0 .. :,., '1' IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO

:MEDICATIONS/SOLUTION DOSAGE . TIME' METHOD PREPARED BY GIVEN BY

_.,

MOUND IRRIGATION 4 YES ❑ NO, TYPE(S):

. ,...„

OTHER ORDERS TIME - CARRIED OUT BY r'k,A_CD,.__Q_.

_ — --

PHYSICIAN'S SIGNATURE

15. X-RAY IN OPERATING ROOM . -- IF YES, SITE

NO cg YES II

16. :LABORATORY SPECIMENS

SPECIMEN (S) . , ..- , ..,. NAME -

YES • NO E '

FROZEN SECTION (FS) NAME NAME

YES ■ NO r4 CULTURE (C)

NO

NAME - _____ __ _ ___. _ ...__

NAME

YES ■ NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

be_co

V._9-i•AX

Y....1./NAX i■ r.)../v ■All,

C2;t'i‘o1.‘ikk '

4.

17. TUBES, DRAINS/PACKING YES al NO •

TYPE/SIZE 120S

.. _ . 2. 3.

SITE if-,

.R) \ACT.A.Aek,

2. 3. ,_ .,„,,_____

19. ADDITIONAL INFOR gi

s/\/\( — CY\ .. ((): '.(..._ :, ..

itlkil.gki2Vi O■ . . . _ .... ,_

20. OPERATION(S)

-_-L--1 T

PERFORMED

1 c.,,,,t-A_Q L E 1e

21. PATIENT TRANSFERRED TO

I OA UAL%) A7 Cfb '1-'

T I M E ' ■2.2._

. it- 33

METHOD

Uti-Z.J.V 22. RE (STERE 1

‘ \.I MEDCOM - 23468

DOD-037046

ACLU-RDI 1681 p.28

. MEDICAL RECORD INTRAOPERATIVE. D" ''':UWIENT For use of this form, see AR 40-407, the - the office of The Surgeon General.

1. P TIENT TRANSPORTED TO OPERATIr ‘.

VIAS BY -

2. PATIENT WED AND PROCEDURE

VERIFIED BY CPT Ar,J 6 ( e., -2 3. DATE TIME PATIENT ARRIVED

10 Nov 03 IN SUITE

,-, 4. PATIENT IN R

TIME (103 MBER


ri CALM MI ANXIOUS ❑ EXCITED U CRYING ❑ ANGRY ❑ WITHDRAWN ❑ OTHER (Specify)

COMMENTS:

6. NURSING PERSONNEL •

ASSIGNED SCRUB

Spc .

- - - -RELIEF SCRUB

...-- i.i

ASSIGNED CIRCULATOR

CPT RELIEF . .___. _ _ .. __CIRCULATOR .

7. POSITION AND

Q, y

POSITIONAL AIDS (Specify)

LITHOTOMY

a- Liriltitt Dtthi

...-

LATERAL: ❑ LEFT SIDE UP ❑ RIGHT SIDE UP 5 SUPINE • II PRONE U KRASKE

COMMENTS: prbp _ moi nicv-114:_..__-_-. 8. SKIN PREPARATION

HAIR REMOVAL

DONE BY:

METHOD:

COMMENTS:

❑ YES mi OR

DEPILATORY

CLIP

NO

UNIT PREP SOLUTION (Specify) SITE:Il-t-,aryy) SITE - .

8 ttacti vg_. c coi BY WHOM:

BY WHOM:

( ---Z- in of ftuids

U U NURSING • IN RAZOR II

_ COMaENTS: 1\10 Pot/

9. LOCATION OF EXTERNAL DEVICES

- —

•

a 4.

Ground Pad -- Safety Strap =

• -

•

LEGEND X

-

.0- !,

.1* '

--"simml.""4113.01111m11111W-

1-1716P-

= = Tourniquet...-.

. .... .: ,

-----

10. COUNTS

C = Correct I = Incorrect -BILI:-W" C ,i,.:. 1(2, ) l

Other• • First Closing Count , •

Final Closing Count SCRUB CIRCULATOR

Sponge Yes

Vo

0 0 0

I 0

7'

7 7 7

7 Needle Sharp f Yes . Instrument D Yes ........._------- ...,•1)1 f . ' -

- --c-:"- Other ❑ Yes

11. PATIENT IDENTIFICATION Name - Last, first, middle;

4 k0

11111111114.0

For typed or written entries give: Grade; Date; Hospital or Medical Facility;)

( Q.) - ' 11

-'7j1

12. ELECTROSURGERY DEVICEIS) (ESU) YES ❑ NO

, i2 ESU NO: FDIC Z.- 4-D IZSe OAS 4614b I D 5,.. i_3 GROUND PAD:

❑ ZE6U NO:

BRAND Va )(to (GEM LOT NO: 93 53

-• 'GROUND PAD:

III BIPOLAR NO:

BRAND

LOT NO:

DA FOHivi , OCT 87

REPLACES DA MEDCOM - 23469 I IS OBSOLETE. USAPA V1.00

DOD-037047

ACLU-RDI 1681 p.29

13. PROSTHESIS, IMPLANTS 1' ] NO IF YES NAME: ID NUMBER JFACTURER

, J-z.:7;A:,_ ,•,::::,..:;PMEDICATIONS/ORDERSi

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT. BY. ANESTHESIA) YES • NO 7:1, MEDICATIONS/SOLUTION DOSAGE TIME - METHOD PREPARED BY GIVEN BY

, •, . .... — —. - •

WOUND IRRIGATION 2 YES • NO, TYPE(S):.

0.990 r■)S • 'OTHER ORDERS TIME CARRIED OUT BY T Dr JZ _ -


15. X-RAY IN OPERATING RO IF YES, SITE YES • NO

16. s' - = LABORATORY SPECIMENS SPECIMEN (5) NAME

.._ -- , ., ---- — : NAME — YES / NO gi

FROZEN SECTION (FS) NAME NAME YES • NO MI

CULTURE (C) NAME ___ ._ .. - - - ----

NAME YE5 ■ NO N NAME NAME NAME

NAME NAME

- - ----

18. DRESSING/IMMOBILIZATION (Specify)

./ 1 15 6 Le V-e r Arm . NA AS "

)e,j(11 y, VtdilA 10.4114 Pkrlde-r spiA.A-1

Vel‘ art( )

17. TUBES, DRAINS/PACKING YES NO g TYPE/SIZE 1. 2. -' - .

SITE 1. 2. 3.•

19. ADDITIONAL INFORMATION

Suri . AYULS4d1 • cef\)A _Alks,s:fh. i

NC.-Lw i

! 6-evu_val brn.ii-

20. OPEFIATIOtO(S) PERFORMED

T:1. - i) id closLat 0+- al- hand 1,,)(5-Lvad, _ -

z. Clert_vi_ recly e ig;o, Lcuer eAt+. 1-ogiAA-d5

21. PATIENT TRANSFERRED 0 PA- - tk,

TIME

1201 METHOD

V -micirLer- 2 ATURE, frti

VT/ MEDCOM - 23470

DOD-037048

ACLU-RDI 1681 p.30

i .)11-119

MEDICAL RECORD

NSN 7540-00-634-4124

VITAL SIGNS RECORD

HOSPITAL DAY I POST- DAY MONTH-YEAR WiI. DAY irfallInfill11111 3111

.m ..13E1 HOUR ; • - PrIMII" 0 :

•• MIP.1211-41111111Will : : : : -. :

- - : : . . . . . . . .

PULSE TEMP. F (0) c.)

105°

180 104°

170 103°

160 102°

150 101°

140 100°

130 99° 98.6

°

120 98°

110 97°

100 96°

90 95°

80

70

50

40

SPIRATioN RECORD

3. • P - •.

fillitm. 3 • .44 . .

: • • • • - • : - • . . . .

—i

CO

to

C

O (.0 41 O

.) C

O C

A) (.43 C.a

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EM

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C

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3 cp 0

0

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b

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... • • drikignigir. i ::::::::: ga MM. i :.

1111 111

.... .... : : in if 1 billilli .......

III I ::. :II.:

. .

::.

•

I.:: 11111

.. ........... 1111

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60 . . . . .. 111 :: . . : :

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.. . 111 i • 31111111111

BLOOD PRESSURE

im 123/a1111111g111111= ■Mill

AILIMINIMEADIAMIIIIIIMRIA UM km.

17' • - 4 ill ilaire , WEIGHT HEIGHT: .-110. MI bt A

...• t VI; -UP) P t!' • MO 'M z, .,

I§ - ft)

:MIME' ctlaok

ex.J v,

°Pil ' •

---elo '' all) 11 Fq6f

&Mr

3 IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)

REGISTER NO WARD NO.

ICS1 1

VITAL SIGNS RECORDS

Medical Record

MEDCOM - 23471 STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

DOD-037049

ACLU-RDI 1681 p.31

O

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40-66; the proponent agency is the OTSG

'AN

EST

HE

TI C

AG

EN

TS

AN

D D

RU

GS

CO

NT

INU

OU

S/R

EP

EA

TE

D D

RU

GS

S

PE

CIF

Y U

NIT

S -

MG

/MC

G/M

L,

"I"

=C

ON

ST

AN

T IN

FUS

ION

D' i

G (Units) TOTALS TOTAL EBL

wan (\i logil F.am („( i) sp. s`

r'l 1 a TOTAL URINE

C-C ( • AI .

I MI VOLAT % del lagliMillig FLUIDS . SUMMARY AGENT % e.t. CRYS Imo DI -

AIR L/Min . ale N20 L/Min COLL ID- 02 L/Min /111IIMMEIMMII

WITH NUMBERS 6 ENTER IN REMARKS SINGLE DOSE DRUGS-MARK ON GRID BLOOD-

to LINE si e 0 Warmed REMARK 2 immir CI Warmed V* •19ff -----•.------.---- tgt.))- Code dm s with numbers,

❑ Warmed events wiql a

enleris , . 30111 cttel

wo A-_--, ,,c.....,, •

❑ Warmed LOSSES

U• E - ri 1 Vtle-4-1 Cie(

EST BLOOD LOSS ,„-t t"./.1"\)r '

'Aji 1 S STAT UM TIME :,0 t.K 09ce is"

BP-IIIII ■ .

220 , Fe• DIZIEFWEIGM SYMBOLS: trc,...„, -CV /7

f / sir ( S

6 zr-2,6--- Y-

‘0 B BP by cuff 1 • I . ,) 1.,` d OG ../ tt-y0

V 200

HEMAT MN I I I I I (1 06 i 16 ( A 180 : : : : ■

' . ' 11/1/X4111 Heart rate 160 Eggs

CT : : : : . . . INITI • L A A: • cdti aw-52_

Resp rate 140 ■ IIIII , , , ' IIIIIIII : W (.6.L4' MiNtwq 120 marnAixamitilMersPISIMMETAFAMM ,

' ' ' 0/1 11 at/A— in= Itran:dRucec0 100 ' litillii "ain . . = ' ' ' # ME ,

-L NNE . EQUIP ECK T 80 EwAvAl , , 6 _C1,6-Lit-r-52-1 c

,

OK?- N TOURNIQUET

r

60 =NINO UWE Mg

MEM k..1.--6. si L-4 PATIENT RECHECK T-

Lt& EVA OM ' . MEI

X- .U.f . —

40 , , d... Mill OK for 4

TIME- ipYtt PROC- 8_0 PROCEDU -- ANES- X-X 090 Ifif C-Xd

1 1 f I I I ■ I , 20 MIME ' ' IEEE

EMI OMNI 111111•Mii / it/ S>0.' t

>

H f - breaths/min wmieim ...• ir. VT-ml r 1 PLOMMI .1L9It Lk- ,

ut Peak inf pres / PEEP A. MIMI_ s-i- z

d At--1 MODE - St on). Issist). C(on) 11/111 ;NM =HMV

1- 0

14- BP/Auto Cuff r„ to_ ,T CO2 (torr) rep. 32- lairtir ICU Spacily1 ' P/oth 102 (Frac or %) —la fall,_ 'r "

II , 1r wf:

CI

ART line ESpO2 1%) IF illw 1 Pi g . Nip Wilt Steth- PC/ES F; ECG 4V Wil t CONDITION: 50-71"."

ur C Gas analyzer TEMP-site RESP. a SpO 9 iii C./Q g N-M Block (T/4) KI IM I

I ANEST A / PRO EDU'E Al ilk Opp Tr e HR

CC CO

I TIMES 0 CA Start Room End Z Warming Witt Z uj - 1 < y ag9

Cony warmer t Ready Begin End Me k with letters & SYmbols. EVENTS_, 0 explan under REMARKS Position - 0.---1 ----41T-66 ------) a.cc . 6 1 eb •••••

PROCEDURE and CPT Codes: ANESTHETIC TECH IQUES: Describe block technique under Re narks

PATIENT ID TIFICA ION: Type/ or written entries: Name, Grade/Rate, A• i NAGEMENT Intubation route,h1We, technique omOenus_ vopic li CLA? c, L.C3clAe ;At' >4 A ...p`. E

.6-9 wock5 ,

AWAY 47 Medical facility 1 .. Ea............K. or - dr U.. PROCEDURE /7 / a

LOCATION: C"

‘c.(uk-S - 1-\1/4 AN •

DATE:9' ya) 0 3

1— PAGE J OF /

9, FEB 1998 MEDCOM - 23472 COPY 3 - ANESTHESIA DEPARTMENT r USAPA V I.00

DOD-037050

ACLU-RDI 1681 p.32

PHYSICAL EXAMINATION BP _ HR _ R T_ Pain Scale 0-10 HEENT - Teeth

Trachea ,4---212-0.--- TMJ/Neck Oropharnyx

CHEST: oV/4---

CARDIAC:

EXTREMITIES:

IV Access: Ulnar Filling:

BACK:

OTHER:

PREOP ATIVE PAST MEDICAL HISTORY EMS REVIEW Cardiovascular:

Hypertension N Y Angina N Y MI N Y CVA N Y Other N Y

Pulmonary Syst Asthma N Y Bronchitis/URI N Y COPD N Y Other N Y

Renal System: • Acute/Chronic F N Y Gastrointestinal:

Hepatitis N Y Hiatal Hernia N Y PUD/GERD N Y

Endocrine System: Diabetes N Y Steriods Thyroid

Neurological: Seizures Neuropathy N Y Other N Y

Gynecological : Pregnancy N Y

Other Significant Hx: N Y N Y

Familial HX N

NPO Since

ASSESSMENT FAST SURGICAIJANESTHEI1C

HABITS: TOBACCO:

ETOH: DRUGS:

CURRENT MEDICATIONS: ( ) = ordered as premed

()

( )

() () ()

( )

PREMEDICATIONS: None Yes (@ Hrs) /CC mg IV IM PO mg IV IM PO mg IV IM PO

LABORATORY STUDIES:

HB/HCT: U/A: OTHER:

ANESTHESIA PLAN OF CARE PREPROCEDURAL ASSESSMENT (Sedation/Anesthsial Age _&515AYS MCZ44: Sex ( ) MALE ( ) FEMALE

ASA Physical Stat 2 3 4 E PROPOSED PROCEDURE: WT: KG/LB . SURGICAL SERVICE:

1 ALLERGIES:

NPO SINCE:

POST-A AND NOTE (NON ASU) { ) NO APPARENT ANESTHETIC COMPLICATIONS { OTHER

Signed: Date: Time: Hrs

Patient Identification: (Ward)

.ttiaria.(c,S1

WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS

ANESTHETIC PLA { ) MAC { Regional (Specify):

‘ral: Mask Intubation

egal guprdi7. SELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and

s to un erstand and agrees. Questions answered.

'--

_-z_ Date: /YbV)er 3

Time: 63.3/....>-Pa

INF disc

Th

Si • Hrs

PATIENT RECORD COPY

MEDCOM - 23473

SEDATION KEY:

1. MINIMAL (Anxiolysis)Patient responds normally to verbal commands

2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or accompanied by light tactile stimulation. Airway assistance is not necessary.

3. DEEP SEDATION/ANALGESIA. Patient responds purposefully following repeated or painful stimulation. Airway assistance may be necessary.

4. ANESTHESIA. Patient does not respond to painful stimulation.

Previous edition is obsolete •U.S. GPO: 2001-62948300002

DOD-037051

ACLU-RDI 1681 p.33

R.ADIOLOGfC CONSULT.ATION RECUESTiS'EPOF:T

/VI I HI

To_YS

Gs-V\I

.A.... .= O .'. E X..'A' 4•4 "'"A . 1 °'.." r.'f.':: , . ‘, .Y. Yt----) 3.....7'.: OF A' E0=‘ - . (..-fon:.....,....y.

'AE OF 7-;...1ANSCRIPTION rolo.,:"1. e_..--7,

IC: L. 0 C R C,

I

- • F- • : 1.

=■

MEDCOM - 23474

DOD-037052

ACLU-RDI 1681 p.34

Yg •,.. P. iC RE C:IS -.- C,.

:=-7:c..t...:Zsrzo ay •, I YEiS

• 7. • • • 7.

•- •

• •

R.LDIOLOGIC CONSULTATION REO. ESYREPORT

K52f■—. jfi KO'

i cd \t&

Lf YO 1-1 1 c45I AAç

OF .10,N

A ,..:rO L OG f C 1

0...7E OF ;-1.=_?-o.;:(Hart:,. ezy. ' L -.3 .... 7 .:. OF 1- A.=..NS:....P.l. • i 0 :4 (11 0.... '..-, . L.--;.. -... ; 1 •

t

1 •

7... 0 7 A:4 1% • c - -

C FA; :a:•...- - •

MEDCOM - 23475

DOD-037053

ACLU-RDI 1681 p.35

14-97 ull

1-38 uil

0.271.6 ogld

I 5-65 till

6. .1 0.1

iT [IL

31-

RESULT REF. RANGE

3.3-4.7 trunoLii

9S-105 rrsaoLl

1:3-33

EST

LB

LP

LT

NtY

REOLIEST:". •

IL\ tE 8

--

CITEI‘ILSTRY REULTF0RI (Stzeto the ?rivacy Azt of 1374)

SSN/PS SSN: )7_)

L

ioIIL

(let) (vca)

(W)

(Nca)

ALB 4.4 3.3-5.5 G/DL 85* 26-84 U/L ALP

ALT 94* 10-17 U/L AMY 59 11-97 U/L AST 55* 11-38 U/L

••: TBIL 0.9 0.2-1.6 MG/DL GOT 33 5-65 U/L TP 8.0 6.4-8.1 G/DL

INST OC: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0

RESULT REF RANGE TEST

i-STAT

pow' Pt Name:

Clu 111 mg/dL

BUN 10 mg/dL

Na 138 mmol/L

1. 4.0 mmol/L

Cl 10g. mmol/L

TCU 22 mmol/L

AnGap 10 mmol/L

Hct 43

Hb* 15 q/dL

*via Hct

pH 7.329

PCO2 50.7 mmHg

HCO3 27 mmol/L

BEect 1 mmol/L

Sample Type_:

08NOV03

05:53

Oper:IIIIIII j- 1

Physician:

Ser# 42015

Ver: JAN304R CLEW R93

TEST I RESULT

8.0-10.3 rnEiiii

0.6-1.2 rid[

, 128-145 mrr.o1/1

3.3-4•7 runoli1

9S-108 mmol[

18-33 thrnoLl

• •

TEST RESULT I REF. RANGE

(art) • veal

o4.1 ALB

LI;

PICCOLO ----- 08/11/03 REFERENCE Ra PATIENT II:

AE:

LIVER PANEL PLUS DISC LOT #: 3154AA7 711- OPER AIMS DR #: 000 CO2 SERIAL #:k4 Q)=U000100491

03:51 CU MALE \IA-

)2C/2 -E.4

I GUI

BUN

CA.-

73-11S rr:•.'.:11

7-22 mi.-ft!

I R_EPORTED BY:

DATE: I LAB ID SO.:

MEDCOM - 23476

DOD-037054

ACLU-RDI 1681 p.36

MEDCOM - 23477

RAPIDPOINT COAG ANALYZER V4.54 SERIA1 41.105485 11/08/0j 04:09

1 Pi Patient ID: 1411111

- 4-1 1„: lest Name Tet)i Result.= 15.2 sec. Ratio == 1.2 Calculated INR = 1.43 St Si4.mple type:citrated wh. loud

Bi TeA Date :11/08/03 fet Time :114:08

L3 Card Lot :080201 Operator

RI RAP1DPOINT COAG ANALYZER V4.54 M SERIAL 4005485 11/08/03 04:14

'," Patient ID:

Sp Test Name (Cz-

Fie Test Result:. 31.5 sec.

Se. Sample Type:citrated wh. blood Test Date :11/08/03 Test Time :04:10

Or` Card Lot :100208 Operator

At

H

F.Vard: • - 'ScN:ticic. -i-- \ -AT i LAST, FIRST, MI.

L

I

I DATE:

n411111110OB-11-03III) a Q 04:06 Patient I Limits

UK 19.1 H x1083/uL 4.5 10.5 RX 5.37 x10*6/td. 4.00 6.00 0:11JSTSU Hgb 14.6 g/d1. 11.0 18.0 Ha 45.7 Z 35.0 60.0 U?v7T MD/ 811 ft 80.0 99.9 ROSSAL-f TCH ICH 27.2 pg 27.0 31.0 ME 320 I. g/dL 33.0 37.0 Plt 202. 110"3/uL 150. 450. LYX 11.7 *I. Z 20.5 51.1 LY11 2.2 * 110"3/uL 1.2 3.4

(C.e) --t- LABORATORY RESULT FORM I .- Sub;cct to tic Eciv:.•c ■,• Act of [9741 i, ---t: I 1 rivc SS2,:iPSEET-577----------''' 1 .,,\. 3 A5 03 1 S )11=. ti (a- -1 ‹).. ric../ ---- - .. . rooms

Z:S:-.11-7 Rib: R4 VGE

„ C

I LAB ID NO.: .

I Ncgati Yr,

I Nklp vc

I NVA

I-leg:at-lye.

NJA

Negative

0 2 - L 0

I Ne-3-3:ire

NcIpth-c.

N/A

Gram Stain CkzcBld

H. pylori Micro Parasites Malaria

O&P

(1Ik , e

I Sou; cc

TEST' ( RESULT 1 REF RANGE RPF. I I M.S.-1.1i rc

Nioao I I Nicabut Microb io-1 az), -

05. BLOOD •

1.13Ank

SF 518 WITH

nv_tivc4vc

TEST I RESULT j REF. RANGE

' 9.E-13.6 3CC3

1 21-34

L

rE"

f P_EPOR.TED BY:

DOD-037055

ACLU-RDI 1681 p.37


co

7

0 CI Z < 0) I • - • Z uj

(-2( 0 17- uj

1_. F co . Z <

crt

n 2 z

° S ,17) 2 2 r, 1- 0 __ ifj 2 i__

w co < --.1- 1-- 43 2 CO

(r) 6 R EL.>• (-)11 1:: (-) !-- Z It! 0ti

,.•.

DRUG (Units) TOTALS TOTAL EBL

( TOTAL URINE zikree0,,,, /,,, ► PI____

C I- • Z

1

1 --4_ VOLA? AGENT

.c..- f7941/C_ % del F, ,2 .y1 FLUIDS -SUMMARY

% e 1. CRYSJ.SLLOID AIR L/Min

N20 L/Min COLLOID- 02 —:3 L/Min —7—

SINGLE DOSE DRUGS-MARK ON GRID. ,s, WITH NUMBERS & ENTER IN REMARKS

iiiOlic- --

cn 0

5

LINE site ❑ Warmed REMARKS Code drugs with numbers,

events with lettlers

7;7 (9

a 2"th...4k) c ,/,.65re u, ,r9,41 --.4c.a ■ 7 Z4PC)0 (.4114/- .2-6At

D,dc)/1/9-41 /6"6 /k)

,Ifve, /five- /"°7 0 i-/14//1" -

El Warmed XL - — 1 -- 2 .90 ID Warmed

❑ Warmed

LOSSES EST BLOOD LOSS 0- 64)

UR NE -

PH a STATUS TIME -lialve- /5----- 3 r.s--- - .

1, 45 E SYMBOLS: 220

200

180

160

140

120

100

80

60

40

20

I---L- -1 -1-1- • BoSY WEIGHT: . . ,

—, ;

KG LB

BP by cuff

A Heart rate

• Resp rate

BR (transduced)

I. T

T —/-r"

ANES- X-X PROC- 8_0

• t

, . , V ------ — . , .

HEMATOCRIT: "

i-- '

1 1 . ( 400.6.1eve 47- f

17 r9igew-e--)Cer‹. Po.i';

INITIAL DATA: ■ 1

• •

BP-

; , ,

_2(2_ , 57 _ , .

.r., 2 bireii* p< •

A/e /I , Cad Xit,,r4 . -70 /a,e0Ar,27,

IL

RECOVERY AT

, „

. ,

'

,

R-203 ,e — , ----

EQUIP CHECK ' •

TOURNIQUET OK? - Y N

PATIENT RECHECK

' -, __,_

TT 1--

_L -1--1--

L -- -1 -1-

___ • --• --,—,---

OK for PROCEDURE?

TIME-

—i—r ,

—

--"

I / At

t "

_...t_._ i . ' i , , , , ,a

or . I- Z tu

VT-ml

f - breaths/min _ ZY 0

S-V

Peak int pros I PEEP

/MODE - SIpon). ssist), Clon)

LE2

CE 0 r0) ur (..) r.)

In CC 0 i- 2 o

BP/Auto Cuff E CO2 (torr)

BPloth F (Frac or %) .. dr PACU ICU Specify]

OTHER ART line S 2 1%) ,,,, • •

th- PC/ES CG 5 IrKa / 0.__ ,L.' CONDITION: 5'714 e

RESP -7 Sp02- 74, 9. BP-

PROCEDURE

f HR- 77 ANEST ESIA / PROCEDURE TIMES

`Gas analyzer TEMP-site

N-M Block (114)

to Start 'Li Room End

Warming blkt .1 /19,9/ /0 /2c( Cony warmer

Mark with letters a symows. EVENTS__ ...6 0 0 Ready . Begin End

expla n under REMARKS Position - e o,- // 2 3 //, 7 / 05,1 PROCEDURES and CPT Codes:

17 /fit/tit CI— C Z Ocare ° i "1j f" 72) 4?

ANEST ETIC TECHNIQUES: Describe block technique under Re narks

e/✓ C i /1/1 /4 AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

-# 9 .Z/)/W

PATIENT IDENTIFICATION: Typed or written entries: Medical facility

game, Grade/Rate,

(11)."'-' t - ''

PROCEDURE LOCATION: C....ilf

.-.... ----. -- --_ ____

DATE: A.

A9 <63 .127/.../11._.

PAGE / OF

MEDCO COPY 3 - ANESTHESIA DEPARTMENT USAPA VI.00

DOD-037056

ACLU-RDI 1681 p.38

DATE OF ORDER

NURSING UNIT ROOM NO.

BE• NO.

CLINICAL RECORD - DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDIFAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFIC

HOURS

Acti,..4 44. Icta

ATION TIME OF ORDER LIST TIM ORDER

NOTED AND SIGN

-L

-3`

c . Dx- (R) r,4" I4itlitL

(fir

1A- 1--(s- G2 9 ° ROOM NO. BED NO. NURSING UNIT 411-- ?cf.) at\c,-147 - tvb b. I Apift-eD

PATIENT IDENTIFIC ATION DATE OF ORDER TIME OF ORDER

CI)

N O - a., c...►J( A.6 CYC

r -7Ti I U 1"144-J--) ,.._ 10 ► 0 /121^1

ro imp - Lg..0 /00 c

HOURS

_ NURSING UNIT ROOM NO. BED NO. c9 PATIENT IDENTIFIC ATION DATE OF ORDER

0—. 0 Nt.■ Cc

Apt, tto oc1D-ki4 NAN) Dy-- T-a-b G (P meFx

IdD a. LE

4.) (29

B D NO.

()

PATIENT IDENTIFIC

vcvv,IN —c? tb x3 -7t Al\-- Po-) — gx., A Act- qa-io-

DATE OF ORDER TIME OF ORDER

O _ Lfzc, PLTU da6-A)

4-aL4r-ke-e-

HOURS

NURSING UNI

9 /202

DA , FAOPP M79 4256

- Av. ip.,,,1V Qt°

(t) (9+0`) P(4-.) ts-- iv avp

(ti)

RE ACES EDITION OF 'I JUL 77. WHICH MAY BE USED.

MEDCOM - 23479 t A J

DOD-037057

ACLU-RDI 1681 p.39


THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MTCAL RECORD

• i SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION

r \--D ._(-k-


Ct 1000 C80 [ 1 50 HOUR'S`.

LIST TIME ORDER

NOTED AND SIGN

Ai/lb — MA} do de cc. €P OR li, AM /0v 03 0 c 0,

lopoi sste0-11- IVF t.gco (o ull.„ il

Al i AAA- .- A ... • • d L LUM.X34,0)

vi NURSING UNIT ROOM NO. BED NO.


DATE O • OF as • ER

W -V3 IR 16D HOURS 10 tft2

u) ALS, Kk Po) Iz_i-) I_ • ri _ .5-15 D 1 ( IP- 09k, kYt-Px

r sa -1,..,1 x3i-L_ a.sit, A6

NURSING UNIT ROOM NO. BED NO.

AG C e) 4-&5711: ?I) 6 C)

DO (5- Ar 14k- 1 ki Lula,—

ATM OF ORDER TIME OF ORDER

-1-ilork i, it u...e HOURS 1


# 'i..

• 0 . , - . A. op E. \ \

& 0 asiP - (6 10-4-•--P 0 ANA— b,.. i ..1 ' I V OF x3 a

mS0,1 r -Tr Ka ty Q i° 1 P R P Ats.kilui eiv.t. zr 0, Q ° AZAJ

NURSING UNIT RO• BED N s

Z.5-,6 W RA,* ,f Pr— ‘50 0 PO (0 V—V461,/


bkiA,Y- 1--


D 1 c ... ,,, d.,,,c6 & ,.•. i • fli

6 _

• ...• r '•etif 0 NURSING U ,d, •

D FORM 4256 I APR 79 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED .

MEDCOM - 23480

DOD-037058

ACLU-RDI 1681 p.40

CLINICAL RECORD THERAPEUTIC DOCUMENTATIONtARE PLAN ( NON -MEDICATION)

For use of this form. see AR 40-407; the agency Is the Office Of The Surgeon General. proponent MO. ( Yr. 2003

VERIFY BY INITIALING ag**Otaetrin4M*tr.., ''' g INITIAL PROPER COLUMN FOLLOWING EACIt COMPLETION

ORDER DATE

CLERK/ NURSE

RECURRING ACTION, FREQUENCY, TIN

HR DATE COMPLETED

ilf01 06 I I V a n- F., NIDi \/1-VA_ q4-9 ‘3 I 0

.

4V-szn III . . _

•\--c--, S\C-■1B-- Aill

Illi 4)3 ---011pc_t ems- _

- 11111

_ _ 'c2k , (.0\1 c. - - aes--Jai f --3 4° - 0(1 -dpirp, dA,+.

!i n 4 - S cD

PM 01 ,

- 41,

ir .

- - - A at. LL mt-Lckc- 'RoirrA 01111r-An q 4--Q YN-) j

_

101' cl) iiirn 9

-Sioc iz\e■,0-cn.

1 sb - - .

93 _ F__-

s„ \„_,.,\\,), .

■ .1Li I' Ii C dsL.F. /

ALLERGIES: )0, YES

' PCNI

MI NO PRJMARY DIAGNOSIS: -pcC. s(p. VD ;" CD■._,N) t-(V____

VD "BL_ LF_.

ADDITIONAL PAGES IN USE: N. YES MI NO

PAGE NO' PATIENT IDENTIFICATION:

MI6 ACTION TIMES

L6 ' 4q USE PENCIL. CIRCLE ACTION TIMES D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07 MEDCOM - 23481

•••■ Oh am.. N... • • ■■•• • "IP 11.4.• ••• •• Cu. I gun ur 1 UCL. s I Mar nt USED. USAPA V1.00

DOD-037059

ACLU-RDI 1681 p.41

Verity by Initialing

it HERAPEUTIC DOCUMENTATION CARE PLAN z

7 ( NON-MEDICATION) Mo Yr 2903

SINGLE ACTIONS Date to

be Done Time to

. be Done , Time Done Initials Order Date

Clerk Nurse

• i . m Lc) \c_.\k; \ - cie__1- -vc) - Dr- \Ni\f-■&._ , ma( \ (Ps N PO-cc c \ o-_ -ko Te, IrDi \ - / /0/9 /) hrliu r--- --Inoi c79-10

1/ (A/ 0 a, OA A 0 , .\-\- 47c3 -P\C_SD --=) \CAN) 1 - CCrd 72'8e- i0

Ordxped Elr Date

Clerk/ Nurse

' ` PRN ACTION, FREQUENCY

INITIAL PROPER COLUMN FOLLOWING COMPLETION

TIME/DATE COMPLETED

— — — — — —

•

— — — — — — —

— — — — — — — — .

USAPA V1.00

MEDCOM - 23482

DOD-037060

ACLU-RDI 1681 p.42


D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

23 24 01 02 03 04 05 06 MEDCOM - 23483

r1:D a_‘) - a \ ,/

/ CLINICAL RECORD,/

a THERAPEUTIC DOCUMENTATION

For use of this form see AR 40-407; the proponent agency is the

q. 4.:a

. _ TIVERIFY EllyIVI ALING INITIAL N

OF1DER DATE

CLERK!/ NURSE

I


HR DATE DISPENSED

$ 01

Wart1 2 - --C:= \ Ticbcd \--1-- • -ok__.\\] 0..

..,

Ni O\. - A

r fum: AIM

16k-

As. \ Nir

-- MI :-.-Ar♦

ONAL. PAGES IN USE:

\

.F. /py ES 0 NO

r)C—.N--/

K—q71 N--3 cce

PRIMARY DIAGNOSIS:

mc 7._ ? V1-- , ..-. c(,.- 3 -( VI) ?3,_ (E

F: ES El NO

PAGE NO

I --------

DISPENSING TIMES

DOD-037061

ACLU-RDI 1681 p.43

Verify by THERAPEUTIC DOCUMENTATIUN LAKC

(MEDICATIONS) Mo. )\

SINGLE ORDER, PRE•OPERATIVES

Dote to be Given

Time to be Given

)rder Date

Clerk/ Nurse

Time Given Initials

PRN MEDICATION, DOSE, FREQUENCY

\\(Lf`cn \\I c\bc)


TIME/DATE DISPENSED

U.S. GPO: 1998-454-110/95216

MEDCOM - 23484

DOD-037062

ACLU-RDI 1681 p.44

■1111•11•111•

CLINICAL RECORD ■

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) For use of this form, see AR 40-407;

the proponent agency is the Office of The Surgeon General. Mo. Il Yr. VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION


HR DATE DISPENSED ORDER DATE

CLERK/ NURSE

I - I #

$ Id I 0 . l

(V----- - . .P.-S=D \ CACCA-`c ' 14-- \\/

4 \ ker \ "C)\ . (--) V\ i(D\ \ 1 . I •

Cra - 1111111Acce_V -‘--9 N cf-3- lb \dr

kt-_,- --.1")

ALLERGIES- I t.y E

- /

s QNo

PC-

Tot- .6't-/(-7.- \V-1 <P

PRIMARY DIAGNOSIS:

p vc_.(P \-- ic)(=r\ ,f,pc._ -i. V -1) F.3.-- ( F

AD TION AL PAGES IN USE:

YES p NO

PAGE NO i


DISPENSING TIMES

11111P)--

k USE PENCIL. CIRCLE MED TIMES

D 7 8 9 10 11 12 13 14

E 15 16 17 18 19 20 21 22

I N 23 24 01 02 03 04 05 06

DA 1 FFOE'r ;i9 4678

EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 23485

DOD-037063

ACLU-RDI 1681 p.45


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. ) r93-3

Order Date

Clerk/ Nurse SINGLE ORDER, P , PRE-OPERATIVES

Date to be Given be

Time to Given Time Given Initials

D Ai I ._ 2 A. .# ELL /1/P 4-4p/b(5&e

I //A/

,

7-

/

Order/ Expir Clerk/

Nurse / PRN

MEDICATION, DOSE, FREQUENCY INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION

TIME/DATE DISPENSED

gelDate

\EY r Co° Asti

rv3zsors\\! 960 %_

1_

T-ro c,esN c bp, 1 5

U.S. GPO: 1998-454-110/95216

MEDCOM - 23486

DOD-037064

ACLU-RDI 1681 p.46

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this Ione see OR 40.66; the proponent agency is the Office of The Surgeon General

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet '

OT55 APPR9VEO fibre

•

Date: T t■ 1 sf) i 03 Anesthesia Type (Circle)) pinal Epidural Drains

Time In: QQHS IV Sedation Nerve Block Hemovac

NG

JP T-tube

Foley

TL

• al

• ral

ETT

Trach

Other

Allergies: t Cd OR Intake: Crystalloid 400 Colloid

Pre-op V/S: lat-417 it 1 IS OR Output: UOP EBL MI r'-I

Procedures: (40'6 \P Meds/Times: I,,,, ArceF- , ,,c,, rnr ce,,,,f- SC Li 21-)Pfat'-•

Pre Op Meds History,

Time ‘1,2 2 . ). . .

I§ . :4 ' -. ;

. Z. tak Pacu In —.

Sa02 Ti it rft trn Tim Solution Amount Site • By used

Fi02 MN Methods RA& tik p _A eFt 240

220 X-ray . Labs:

Post-Anesthesia Recovery_score

200 Criteria ADM 30' DM . Codes Activity

(2) Moves 4 Extremities (t) Moves 2 Extremities (0) Mo 0 Extremities

AIRWAY

A= Ambu

BB = Blow -by

M = Mask

180

160 Airway (2) Cough, Deep breath

Dyspnea. limited breathing (0) Apnea

FT =Face

Tent_ I (I) OA n. Room

140 NC = Naiir" Blood Pressure (2) SBP =I- 20 of Pre-op (1) SEI P =/- 20-50 of Pre-op (0)SBP 4-50 of Pre-op

Cannula

V/S

X :. 'ne BP

120 V, i V "V V.‘„,

100 '4 . Consciousness

(2) Fully Awake. audible trying (1) Arousable to verbal or pain

drianlil■ = Pulse

TEMP 80 • • • • • Color

(2) Basehne color & appearance


S = Skin

t3eralc

T = Tympanic

60

A INA,\ A


R = Rectal

LOS C = Cervical 20

TOTALS: Must be 9 or greater to D/C, otherwise needs anesthesia approval for ID/C.

T = Thoracic

L = Lumbar

S = Sacral RR N II II (0 T 0 , Time Patient teaching done; Wound Care. Pain Management. I

Pain (0-10) T. C. 8 DB,. Incentive Spirometer. Comfort Measures

LO Safely: SR up X 2, Falls Precautions. Privacy Maintained

P

i ib •(e) -.-

0 TMENTISERVICEICLINIC

ACU

aonrinue on revenel

DATE

03 PATI pe or written entries give:

first, middle: grade; date: hospital or medical facility)

jD ( (:,) ' ,

Name -last. ■ IIISTORYIPHYSICAL 9 FLOW CHART

In OTHER EXAMINATION • OTHER tsprarr

OR EVALUATION


• TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 ( MCXC-DN)

MEDCOM - 23487

Previous edition is obsolete USAPPC 02.00

DOD-037065

ACLU-RDI 1681 p.47

Time Route Pain 1-10

I/E 13y Pa Medication & Dnsane 1-10


PACU OUTPUT

Discharge Criteria:

Date:gNOVI5S Time: 103 a PARS: 9 BP: lupt590 T: 47 • I HR: r71 RR: Sa02: Pain Level at D/C (0-10): — Intake: Output: Additional Data: A.)0).%-/C Transferred To:_ IC t/L1

Report Given To: Transferred Via: W/C Transferred By: Cleared IAW Recov Charge Nurse Signature:

Ambulance

7 NEUROVASCULAR Time Site Range

Of Motion


T Color

Adm 61615 -I- -I- P fl) C. VI 15' P(09< .--t -t P Y3 C f' 30' iNe5r 4 't p 6 C 45'

60'

90'

D/C s (e5, e 4- ri 0 C Movement/Sensation: + = present,- =absent Temp:C = Cool, W. Warm Pulses: P= Palpable, D= Doppler, A = Absent Color: C -= Cyanotic,

Capillary Refill: B= Brisk, S=S uggish P= Pale, Pk = Pink

C-SECTIONS

Adm 15' 30' 45' 60' ......913:—,—D7C--- Fund. Height

Lochia ---------- Peripad#

Fund. Con __.--

-..,..,_ DRESSINGS


Adm 0955 a le3,S iCevles,- rv■.1^ 30' 6 fe3 c veytekc I.", h•-■

60'

D/C f3 irr\ s , IceAr lex ta.1 i...)

NURSING NOTES

received 'Pon, OR s/{) 1-'4) ( 13)456 harti • "4 SpOz PA Klo rib tA2ir-1

eA, (V) C/O

Time

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? OC4.5 5 NS's o cp

WAMC OP 173-E

Source • Color/Agpaance Amount

MEDCOM - 23488

DOD-037066

ACLU-RDI 1681 p.48

REPORT TITLE

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this lana, see AR 4066: the proponent agency is the Office of The Surgeon General.

OTSG APPROVED !Dater Post-Anesthesia Care Unit (PACU) Flow Sheet

Name - last.

❑ FLOW CHART

❑ OTHER aNa,./

❑ HISTOLPHYSICAL

❑ OTHEipAMINATION OR EVALUATION

O DIAGNOSTIC STUDIES

❑ TREATMENT

MEDCOM - 23489

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPPC 52.60

DOD-037067

Date: l b ki 0-4 CL3 Anesthesia Type (Circle)): General Spinal Epidural

Time In: 14, (..--.) IV Sedation Nerve Block

Alleigies: %--)V---6\ OR Intake: Crystalloid 'Z," Colloid

Pre-op V/S: 111 57 ) 03 0 Output: UOP EIBL 5-0‘.1— Procedures: j+ IN Meds/Times: 1 --rl-rar)L, j '

IP xti 1-ttS

-(:).- istor

Drains Airway Hemo c Nasal

C_Ota1 rP ETT

-tube Trach Foley Other TLS Pre Op Meds

Site Time Solution Amount

I? 00 By

1:>koilf6 Infused

- z_sn

X-rays: Labs:

Criteria ADM 30' Codes

z, 2_)

Activity

(2) Moves 4 Extremities Moves 2 Extremities


Airway (2) Cough. Deep breath (1) Dyspnea. fimited breathing (0) Apnea

Blood Pressure (2) SOP. =4- 20 of Pre-op (1) SOP =/- 20-50 of Pre-op (0) SBP =I- 50 of Pre-op

Consaousness (2) Fully Awake, audible crying (1) Arousable to verbal or pain

Color (2) Baseline color & appearance


Circulation (Peds < 5 Years) (2) radial Pulse Palpable (1) Axillary palpable. not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for DIC.

DEPARTMENTISERVICEICLINIC

iltaL

AIRWAY A= Ambu BB = Blow-by

M - Mask

FT= Face Tent RA = RoomAir

NC = Nasal Cannula

VIS X= A-line BP ,

=Cuff BP = Pulse

TEMP

S.= Skin 0= Oral A = Axillary T = Tympanic R =Rectal .1

LOS C = Cervical T = Thoracic L = Lumbar S = Sacral

RR

T Time Pain (0-10) LOS Safety: SR up X 2. Falls Precautions. Privacy Maintained

Montrone on reverse!

DATE

lb ID

rl

Pacu Intake


5, a Time

Sa02

220

Fi02

Methods

240

200

180

160

140

120

100

80

60

40

20

Patten teaching done; Wound Ca e. Pain Management. T. C, 8 DB,. Incentive Spirometer. Comfort Measures

Or ed w written entries give:

list middle: grade: date: hospital ar medical tank)

ACLU-RDI 1681 p.49

PACU OUTPUT

Source

Colerfl‘earance Time Amount

Transferred To: Report Given To: Transferred Via: Transferred By: Cleared lAW Rec

(‘ I

0

Gurney Ambulance b 10- t

- 23490 .e Signature:

MEDICATIONS Allergies: Time

V


Of Motion


T Color

Adm (i)a ilit LIDP1 -I- . 6 ki Pig 15' g LI. re iyiut_ -- f —B b\I 12 le-- 30'

45'

60'

90'

DIC

Movement/Sensation: + = present,- = absent Temp:C = Cool, W= Warm Pulses: P = Palpable, D =Doppler, A = Absent Color: C= Cyanotic,

Capillary Refill: B = Brisk, S= S uggish P= Pale, Pk = Pink

C-SECTIONS

Adm 15' 30' _.--45-----60' 90' D/C Fund. Height ----"------- Lochia

Peripady-------

„Red Cond.

DRESSINGS


Adm (6 tiZri,-- V L/ rit "Z-k t

c..--:-.7:=)- 30• E. LL, 60'

DIC

Pain 1-10

Medication & Onsaae

Route By

NURSING NOTES

k kStrvAq /1(6-mu Ls fp I -I- (6 -hard_ a-) X_ b;/

eftAtc. ic-41vAti t LI)--L

-)/4 ZX Z Lv /i )-)-PAJ JOTirvite,Y

ft "Lriki rikou 4\( trr(ae5f- . i V

bitA{)1AHLI/iy) -h). Orli et ILL(

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run?

c=:=,- 1 .Z.DO Ste _, c:L='-.

WAMC OP 173.E

Discharge Criteria: Date: loy.la-1( Time: / PARS: jo Bp: IDbiy tl' „ T: 9HR: , RR: a/ Sa02:q5— Pain Le er at D/C 10-101: Intake: 21 ) Output: --,-C---;) Additional Data:

DOD-037068

ACLU-RDI 1681 p.50

BLOOD PRODUCTS

❑ D-stick

❑ SHct

SBC • ,4:1 Chem ji(PT/PTT

:SIZE ACOOMPANEC, rrE

❑ Oral

❑ Nasal

Teeth

RESULTS ;-

O ETCO2 Change

❑ BBS Post Int

❑ Post CXR

fiOCEDURE

CT Scan: ❑ Contrast

❑ Head ❑ Abd ❑ Pelvis

PROCEDURE

ET

Intubation

❑ Air ❑ Contents

❑ Verified

Suction: Y N

❑ C-Spine ❑ T/L Spine ❑ Chest Gastric

Tube

❑ Oral

❑ Nasal

A-Gram Site: Urinary

IV ACCESS & FLUIDS ❑ Meatus

❑ Supra-Public

❑ Return

CC

❑ Herne Dip: + -

0 Secured AMT DPL ❑ Grossly: + -

Cell count

Sent@

❑ Opened

❑ Closed

❑ Air ❑ Blood

❑ Pleuravac cm

❑ Autotransf user

Chest

Tube #1 L R

Chest

Tube #2 L R ❑ Air ❑ Blood

❑ Pleuravac cm

❑ Autotransf user

12 Lead

MEDICATIODJS

AMMO =AIM M

MEDICATION DOSE TIME DOSE R PQSE

sO

Rhythm:

Comments

IC /5

ABS: PM

❑ Chest Initial ❑ D-stick

0 SHct

❑ Chest Post ET

❑ Chest Post CT

❑ ETOH ❑ T&S O T&G.-x ❑ C-Spine Mt* ❑ Tox Screen ❑ Pelvis

UA ❑ HCG

❑ OTHER

❑ OTHER

INTAKE & OUTPUT

INTAKE U Amovto- CBC: Chem: OUNT

c..)4, /0

IVF

NGT

Urine

NGT

5, /

P7/z7

2e2

/s-, 1/31 ;

Blood EBL

Other Other

TOTAL TOTAL

--- LE

TRAUMA TEAM 1404,—,E,t,,

AF-RIVAL

Eiikiiiiimi '

VALUABLES & CLOTHING , .

D Phys None Found

urgeon Given to Patient

nesth Given to Family

Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696

❑ Home


DISPOSITION

❑

X-Ray

RT

Ortho Admitted to

Neuro Report Called to

Transferred Chaplain

MEDCOM Time

- 23491 By

E

S

DOD-037069

ACLU-RDI 1681 p.51

4 - Spont

3 - To Vo

2 - To Pai

1 - None

3 - Inapp Words

2 - Incomp Speech

4 - Confused

5 - Oriented

13(g/73

PC/13

0396 f7/0 6 is-z to 04-01 IP oq w 12014o

Temp:

TIME

ti) 1) 3 I C

tr- 110

GLASGOW COMA SCALE VI AL SIGNS

GCS:

"SA°2 FiO2 :MODE'

1 - None

13.0CdijiME:: 0 Backboard Removed

CI Downgraded

.

-:NIOTOR;RESPONSE -,'`.

6 - Obeys Commands

5 - Localizes Pain

- Withdraws to Pain

3 - Flexion to Pain


1 - None

.,.,PERFORME1); EY:,

BY:

BY:

RR'

10

VREBLE RESPONSE

-z_ '1

fr

MOO pi,- A - ekLi e.c

e3oLLA ----/

p c:a ■ l■ Or

MEDCOM - 23492

DOD-037070

ACLU-RDI 1681 p.52

E ki !'-'U pi pi 6-- j et_

0 75

A-An° 3

e vp,

Ow.

MEDCOM - 23493

DOD-037071

ACLU-RDI 1681 p.53

AIRWAY BRETHING CIRCULATION

,LEkNatural Patient

❑ ETT

❑ Secretions

❑ Labored A4 Unlabored ❑ Absent

TRACHEAd Midline ❑ Deviated

CHEST SYMMETRY:

13

ci

PULSE: Present ❑ Absent

BLEEDING:

HEART TONES: ❑ Clear 0 Muffled

SKIN: )Warn ❑ Cool ❑ Hot

❑ Pink ❑ Pale ❑ Cyanotic ❑

Dry ❑ Moist ❑ Diaphoretic

SECONDARY SURVEY "DISABILITY'

GCS: E

V

HEAD

PUPILS: Equal ❑ Fixed ❑ React ❑ Dilated

TM: ❑ Clear ❑ Blood

HEART

RHYTHM: C14115trlar ❑

ABDOMEN

oft ❑ Rigid allNon-Tender

❑ Tender:

13 a a PULSES: ❑ Central ❑ Peripheral

M

SPHINCTER TONE:

❑ WNL

❑ None

NECK PELVIS

Getable ❑ Unstable ❑


Herne +f - Prostate: ❑ WNL O Abnl

USE DIAGRAM TO' DOCUMENT INJURIES AND PAIN VASCULAR ASSESSMENT

(AB)rasion

(AMP)utation

(AV)ulsion

Battle's Signs

IBLIeeding

IB)urn

ID ► eformity

(E)cchymosis

(F)oreign Body

IH)ematoma

ILAC)eration

1Pluncture Mound

(Pain)

ISleatbelt (S)ign

(SItab (W)ound

IGSW) Gun Shot Wound — )2

+ + Strong + Palpable D Dopler

(Continue on reverse) DATE 3

PHYSICIAN

DEPARTMENT/SER E/CLINIC

ENTIFICATION (For typed or written entries give: Name--last, first, middle; grade; date; hospital or medical facility)

•

411111110 (1 -



❑ TREATMENT

❑ HISTORY/PHYSICAL ❑ FLOW CHART

❑ OTHER (Specify)

DA I FP ZYM7 8 4700 D BY DD FORM 2CO5. EAMC OP 503, 1 Dec 98 MEDCOM - 23494 _ETE.

LUNGS .

BREATH SOUNDS: ❑ Bilat ❑ Equal 0 Clear

II II

a a

Decreased a Absent

Wheezes LI Crackles

C-Spine Tenderness:

Pain @

a

JVD:

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.

REPORT TITLE TRAUMA FLOWSHEET The proponent is Dept of Surgery

OTSG APPROVED (Date)

01 Appr 11 Jun 97

TIME:

MED COM: a ETA: 0 IV x r ❑ 02 . Vrnin ❑ C Spine Immob

Meds: ❑ UKN ❑ None ❑ Yes:

Allergies: ❑ UKN ❑ None ❑ Yes:

Tetanus: D UKN 0 Current Last Meal/Fluid Intake hrs

LMP:

PRIMARY SURVEY

DOD-037072

ACLU-RDI 1681 p.54

>,Q

1. Reporting MTF 2. MTF Loc....—•

IZ Admission and Cod,ng Information

For use of this form, see AR 40-400; the proponent agency is OTSG

3. Register Number

0015197

Name (Last, First, MI)

(_4 3\

4. Pay Grade

FGN

i 5. Sex

M

6. DoB (YYYYMMDD)

1979-01-01

7. Age at Admission

24Y

8. Race 9. Ethnicity

X 9

Religion ‘

10. Length of Service ETS 11. FMP 12. Social Security Number

99

- Organization (Active Duty Only) 13. Marital Status Hour . of Admission

03:00

Branch / Corps:





DIS

Prey. Admission

NO


Direct from ER

Ward:

ICW1

Name / Relationship of Emergency Addressee

Address of Emergency Addressee

- • cility: i ,_ Telephone Number of Emergency Addressee

21. Type of Disposition

TRF-OTH

22. MTF Transferred To 23. Date of Disposition (YYYYMMDD)

2003-11-13 /


AEA - ORTHOPEDICS


2003-11-08


2003-11-08

FOR LOCAL USE


Admission Diagnosis Narrative: S/P VD R IF DPC OPEN MC FX VD



k

Admitting Offi :

BL LE

Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 23495

DOD-037073

ACLU-RDI 1681 p.55

4. Sex 5. Age 6. Race

M 32Y X

7. Religion 8. LnthOfSvc 9. ETS 10. PrevAdm

NO

14. Ward

ICW1 11. FMP

99

12. SSN 13. Organization

MOM

Automated Facsimile - DA FORM 3647, May 79

Automated Facsimile INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

e ister me 3. Grade

FGN

Admission Remarks

15. FlyStatus 17. Dept / Ben ' 418. BranchCorps

K78-PRISONER OF WAR/INTER

19. UIC i ZIP 20 Type Case

BC


Direct from ER

22. Hour Of Adm:

03:00

23. Clinic Service

ABA - GENERAL SURGERY

24. Name/Relation of Emergency Addressee

27a. Address of Emergency Addressee

29. Re orcin MTF t,

01111.111.1




25. Type Disp 26. Date of Disp

TRF-OTH 2003-12-17

27b. Telephone No 28. Date This Adm: AdmittingOfficer .

2003-11-08 IMO (66

30. Date Mit Adm 32. Units Blood Components

2003-11-08


34. Diagnosis / Operations and Special Procedures:

GSW L BUTTOCKS AND THIGHS

19-6,a 10 02 / t

ges-S-7

35. Total Days This Facility

Absent Sick Days Other Days ConLv / Coop Care Days Supplemental Care

0 C 0 0 Bed Days

Total Sick Days

1-a 35. Total Days This Facility

Absent Sick Days Other Days ConLv / Coop Care Days Suppl*ental Care Bed Days Total Sick Days

avitor**: ,o Signature of PAD or Medical Records Officer

(

MEDCOM - 23496

DOD-037074

ACLU-RDI 1681 p.56

IDENTIFICATION NO. ORGANIZATION


MEDICAL RECORD ABBREVIATED MEDICAL RECORD PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITI N N ADMISSION (Eair date of .1 Ini?fiott

ilk 1 114(1i

S /?, J'e s

r

Lail '9-5%14C4(

/ ier7r= Itl/2,1.0 Oa= /.-z

g 771172 /1/2<14 •

PHYSICAL EXAMINATION

7 . /02 /V :- /1(0/7 i r (0 ('4? (r'' ' / EA,

14: i 1 A / : _ e ,,,eia tio, f,ori ad,d;

PROGRESS l „= „/6„ clale( 6)/i„Anr„and final dtil„724cjj

cf fcciki /go( (11A va° 0-7

NI 11111111111111111 A I E '5 '5 IOENTIFiCATION (Fodr dry.P ii.

1 heon:;: te.eitee

Dtkv03 d elv1Z7

ABBREVIATED MEDICAL RECORD Standard Form aft

GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106

/IT MEDCOM - 23497

k 4/7,1{ Jd vo.46 I

DOD-037075

ACLU-RDI 1681 p.57



DATE NOTES

(MVO S? 0 ejcb Jed PI . °I NY\ (t b-ta_ ti o/c) . 1)7_0,12_14)/v if • • 1 1 k i a ..1.1)4, iii_ti affils <bpii. . F 2.' , __L :„, _ ws M. 11/F_IUS- a_'- 26 MG (p r-CL etzsL c fill>, Aix 1125

j. ' , 77V e h-c , • -I .4 1 4 .I4 . 4/106 4 06 .. Ai /L' )-td 76

-5.,-,.c ' oar #,

"e4,c, L.,./,/i2 , . L ,

I _Lac /0, ,16,,L,er • (7, -0 (32Acz.l.„; ,,,i

IBP TREND

TIME

HH: MM

HR/PR 3p02 SYS / DIA

BPM X nolig - MEAN I

RI 08:10 92 100 139 I -,6 101 08:00 103 100 145 / 24 102 07:50 91 100 141 / ?D 103 07:40 94 100 141 / 77 101 07:30 92 100 166 / 77 110 J 07:20 97 100 139 / 70 96 07:17 09 inn 1 /

OF)L-I 3 Da• I -01 ,1 .1 tat 0,4 ,A ultDri({, • Ribttathrith flGet ,oxj

gLopkicpci tA.> i-Ltv, 1,:r 44,4;r__ «Z. 6) ;)4!.. Ap /,'

ti /(/(j-' cqi)() a /Off/ -43— 0-E-PP-0.1r) '&00J9

, 1P A( till i

. AO( 0 t ,)

(''Ykill ,,de

.

0 tide 11 1 to -1e5 intoldeo ( )1617-0

, Q,Fr-----

RELATIONSHIP TO SPONSOR SPONSOR'S NAME IMI

I SPONSOR'S ID NUMBER

(SSN or Other) • 4

.-

LAST

•

HIST

, ..---- ...,---,. DEPARTJSERVICE HOSPITAL CR MEDICAL FACILI

PATIENT'S IDENTIFICATION: (far typed Of written entries, give: NNW • lay, fen, made; No a SU; Sex; Date of Beth; .9ank/6tede1

vw1111li

••••■••11,11■111••••••••=..,

..■111.11

PROGRESS NOTES Medici! Record

STANDARD FORM 509 my:. 511599

Prescribed h•..• GSAIICMR FPIAR FlItER) 101.11.2231M

US' PA V; CO

rEGISTER NC. WARD NO.

MEDCOM - 23498

DOD-037076

ACLU-RDI 1681 p.58

LAST NAME FIRST NAME 1 MIDDLE INITIAL ID NUMBER

DATE NOTES

I UNA .01

:- 6. I 0--g ( /4, ‘,/_7616 41- -7e, iri of-61 K La

)Ce, 6 '' M 1 ,i7e) ,/ - / 61ifi-oi--/ '7

/1/414(,La

= 6cc i

fx,,,_._4tt. ..9.//0____L

c., %

'(- ' e_C • (I/ — / --a- ' f O cii- -I— . A .4-i Q--(c, 4 7 e

01- i-k-- 2 g'; /

6 / Pi:6p/

Ili 2 57 o

7 3 7/t. e72z l 71k

MEDCOM - 23499 STANDARD FORM 50S IREV. 5119991 I3ACX

DOD-037077 ACLU-RDI 1681 p.59



DATE NOTES _

ab 1 Mtn J A. I Li I i la A I a' i • 115 1 113- `R )5 7 $ • )' ol E, -0

Ilitil itA l I LI i . nu _i fill 1 NMI Nith 1'p t. A i ■iwi,' --/ t I, a II Si A' ) ti ild 1 I

I

111 LLA al PIN - it" r 0 I i A ' v

. ' Illit

i tie a . I i 9 ' ,

le , I _.:Awaysimir

1

II I

RI), 1 A - 9 . Parallial 1 1 I 0 Ateillff

- 011101101=ffii dilWa' h oli _ riliMMNIATEST Alt 1 WM I L Al ' Ai dal At O. t fil A I LIJIMT I I / tig I i A. 4 /112 i kV_ /ii AL_I _

/GV

• I

-1: rAMIi■ I Li ) AIM CIU 'wi aik rif 4ta _ , „ A ae. • morel, ,..... Oaf I fik ki..7 .; 1 MIS

, triMIIWIP. - , r 1 A itlIMIIMIMI . .0.24r

/ -6- / ■ i A • J , i ./..., i - i••■ 411110, .,

RELATIONSHIP TO SPONSOR 4/4.

SPONSOR'S NAME LAST FIRST MI ISSN Of 'Other)

DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENT'S IDENTIFICATION: (For typed 01 written entries, give: Name • last, lin mahlle•

/D No ar SSM- Ser; Date of Birth; Rank/Grade)

‘ I /. N . i

REGISTER NO. WARD ND,

`-P-PLU 14111111 MEDCOM - 23500


STANDARD FORM 509 IREV. 511999) Prescribed by GSAIICMR FPMR I4ICFRI 101-11.203(bIl1al

USAPA VI.00

DOD-037078

ACLU-RDI 1681 p.60

1ST NAME FIRST NAME MIDDLE INITIAL ID NUMBER

DATE NOTES •

)462- 1- Rizo &PT, _:Zel)

i . h Le_ - 0,,/) AA. e (7,6 --7 k (),P61/.

I

MEDCOM - 23501

STANDARD FORM 509 niEv. 6119091 BACK

DOD-037079

ACLU-RDI 1681 p.61

STANDARD FORM 509 (REV. 5/1999) BAC:

USAPA VI

MEDCOM - 23502 0161 -111iIktj

DOD-037080

ACLU-RDI 1681 p.62


MEDICAL RECORD I PROGRESS NOTES

DATE NOTES

Th *-0,.,,,sF,2_,/,,-,1-1-r, lad I ..,-,,,-, I( k_i i ul, -H-e-•• A--, '; 1.-0 i f ec9-----a-.1-1, 4,-,---j A- 1 V5 5, ,,-1--- 1

• i, . ,1,3 * ,,--, . "2._ k i ' IL ' ' S - LS C

g 5 (....k.6 ce c4i- AJ I> FT 6,... nwZ nev c.̀...5 i G c, - —szli ',A, L.,t,r ;%,„,„,_; cz.„... („7„..t ,„.,,,,, r_7(--,,,,po i

AA, d ‘,.. . • / 1.1. '_ " , _,_ A., __. C: 0 I. -)L, -

, A.0, v( 13.0_5C 4 J

.-1 , __ • .,.. I S 1 4 — Y KL .,.., 0_,,..

IAA ( 4' ' 1 C Fs'511- 6 1 P-'4/ (..c., --- .-1- ,---- --- ---i c T _ ...,_ ,-.. -ea.

_

(4...e._ '- -1-e-c-

a_C:x7D d- 4-cfec.--_ (9/2_- (07Lortx)--i -- -_ 5c-- . ilk __,j

Cte - a- 4/ .4--,_ac.___< A2 k A, NS c apr-LEzkcoi_Q e Rs-,

p (We c.„---) . 4hi ,4/-6 >i ,c--)-2 .___ 06La6--2,-eiZ - 60`-' I /

/ / K-4!.,

A/ Or...11-...1i1AM II I,, etA-,66 -*dC_ /

16b.. da-i--d--- ---6,-1,----

e (.-. 2-7.--- "LA %....... /id • ...-4 vl ...._14,4 , ' ./Ail,2... v .,.

cx). / 2ck) cc_ - -ALA IL . 41, •

Ant ALAI • Ar' -

fa I II ■--e-,....fg"

•

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ACLU-RDI 1681 p.103

NSN 7540-00-634-4124 511-119

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<111111P VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41.CFR) 201-9.202-1

MEDCOM - 23544

DOD-037122

ACLU-RDI 1681 p.104

VITAL SIGNS RECORD MEDICAL RECORD HOSPITAL DAY

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PATIENT'S IDENTIFICATION (For typed or wri ten entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)



MEDCOM - 23545

DOD-037123

ACLU-RDI 1681 p.105

511-119

MEDICAL RECORD

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VITAL SIGNS RECORD HOSPITAL DAY

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REGISTER NO

VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 23546

DOD-037124

ACLU-RDI 1681 p.106


POST- DAY

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1111011111iiiiitar...._

REGISTER NO


MEDCOM - 23547

DOD-037125

ACLU-RDI 1681 p.107

5. ADDITIONAL INFORMATION: (Previous surgical and medical history) Tobacco ppd X_yrs :ody P' rcin - Diabetes (Y) (N)

w',ETOH ff. W

sease

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT MEDICAL RECORD

FOR Use this form. See AR 40-407: the Proponent agency Is The Office of the Syrgeon General.

1. AGE .3\

HEIGHT: ,

WEIGHT:?

2/- NOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication) A—ICIKDA ❑ PCN ❑ LATEX ❑ IODINE ❑ TAPE ❑ FOOD •

REACTION:

3. PREVIOUS SURGERY [ ] YES (type):

4. PROPOSED SURGICAL PROCEDURE:

1M\ u_OicY (jf ASA/Motrin W 72hrs (Y) (N)

s ma COPD) (Y) (N) Anticoagulants (Y) (N) Herbal Medicines (Y) (N) MEDS:


Skin Condition ROM

act (Y) (N) . Dentures


A. PSYCHOSOCIAL potential for anxiety related

to: >C> 1) Surgical Procedure&

Operating Room Environment XS) 2) Separation Anxiety

CCdd

\• 3) Surgical Outcomes

Hypertension (Y) (N) 7. PATIENT GOALS AND EXPECTED OUTCOMES

O Pt. verbalizes any specific anxiety.

O Pt. Exhibits relaxed body posture.

0. Allow pt. to verbalize freely.

0. Explain Or environment and answer

questions regarding surgery.

0. Offer comfort measures. (e.g. warm

blanket. touch).

0. Explain all nursing procedures before

they are done.

0. Remain with pt. Whenever possible.

0. Maintain family interface. Parents to

stay with pt.

B. AERATION Potential for respiratory

dysfunction due to: \\O 1) Positioning

2) Effects of Anesthesia

3) Medical/Smoking History

O Pt. will be able to breath without

difficulty during immediate intraoperative

phase.

0. Offer to elevate head of litter or offer pillow.

0. Observe pt. While awaiting surgery for signs of distress.

0. Assist anesthesia during intubatior

and extubation.

C. INTEGUMENT 70 Potential Impairment of Skin

Integrity due to: 1) Intooperalivearnaokilfly

r>0 2) ESV__Pad Placement

\,/-1 3) Positional Aids

4) PEgstheis V, 5) Pooling of PrepSolutions

O Pt. will exhibit signs of impairment of skin integrity (e.g., reddened areas).

0. Utilize pressure preventing devices

on OR table and accessories.

0. Check for proper positioning and

support to maintain good body alignment.

0. Pad pressure points.

0. Place ESU ground pad on non

compromised skin surface area.

0. Keep prep fluids form pooling.

9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)

L dk

VERIFICATIONS AT HOLDING AREA: ! Dentures Removed

! Contacts Removed

! Jewelry Removed

I Body Pierce Removed

! Consent/Blood Transfusion Sig ned/VVitnessed/Da ted

! Surgical Site/Consent verified by Pt./Anesthesia/Surgeon

! Contact precautions (Y) (N) ! Family/Friend:

ID/Allergy Band

! H&P

! NPO Since

! UHCG/LMP

DA FORM 5179, JUN 91 MEDCOM - 23548 USAPA VI.O

DOD-037126

ACLU-RDI 1681 p.108

E. NEUROMUSCULAR CONTROL E.I. -Potential Impairment of

obility due to:

Pain

Intra operative Hazzards

prosthesis

Positioning

Transfer pt. To/form OR table Potential Discomfort Due to:

Length of Surgery

Positioning Arthritis


D.-NC4CULATION otential for inadequate tissue

perfusion due to:

>0 1) Intraoperative Mobility

\IO 2) Positioning

Sr") 3) Existing Disease V") 4) Safety Devices \,9 5) Hypothermia

7. PATIENT GOALS AND EXPECTED OUTCOMES

0. Pt. will exhibit signs of adequate tissue

perfusion (e.g. color, warmth. pedal pulse.


O Check foe support stocking or ace warps. if none, check with doctors.

O Check that safety straps are

correctly applied.

O Offer pillow for under knees.

O Place and take down legs from stirrups with slow bilateral motion.

O Check that rings and all body piercing has been removed.

O Have sufficient people available for transfer. O Insure proper body alignment.

O Allow patient to lie in position of comfort while waiting for surgery. O Offer support (i,e..pillows. Bath towel. etc) for positioning.

O pt. will be transferred to OR table without difficultly. O pt. will be not experience unnecessary

physical discomfort.

F. Special Senses F.1.....,42Diminished visual perception due to being:

K31) pre-medicated

2) W 0 GLASSES

F.2.. Potential for Decreased

Communication due to:

-7,!:-.D1) Diminished Hearing

---Z5 2) Language Barrier

F.3. Potential Injury due to

Dentures:

1) Upper 4) Caps

2) Lower 5) Crowns

3) Bridges

o pt. will be made aware of surroundings

prior to anesthesia induction.

o pt. will be transferred safely to OR table.

o pt. will be able to understand instructions.

o Minimize danger of injury during intraop

period.

O Introduce self. keep pt informed as to

where he. she is and what is happening.

O Inform pt. in which direction to move

and assist if necessary.

Speak clearly and slowly. O Address pt. from side.

O Validate pt.'s understanding of verbal

communication.

O Verify removal of dentures.

G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs

OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes.

OTHER NURSING INTERVENTIONS OR continuation of above Interventions.

10. OR NURSING INT DDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.

infl DATE

11. POSTOPERATIVE EVALUATION : LEVEL OF CONSCIOUSNESS: 1:1 A&O

LEVEL OF ACTIVITY:

12. PREOPERATIVE (Signature and Title)

DATE:0 )A,,,sj

REVERS OF FORM 5179, JUN 91

SKIN INTEGRITY: B vig> pad Site: Clean and Dry ❑ Red ❑ N/A

❑ Drow

EXTREMI/TIES

❑ Trahsferred to Litter With roller due to spinal

P PARED BY 13. PREOPERATIVE EV PARED BY (Signature and Title)

USAPA VI.0

VES ALL

leepy Ointubated Moves Up-cie-l'Extr,emities

ESSING DRY & INTACT:

(N) ATHING EASY: N)

TIME: 01P DATE: M TIME:C2

MEDCOM - 23549

DOD-037127

ACLU-RDI 1681 p.109

INTRAOPERATIVE For use of this form, see AR 40-407, the pro:

1. PATIENT TRANSPORTED TO 01-._riATING !.. A

VIA GAA' 1 BY f4 2. PATIENT ID

VERIFIED BY 3. DATE

62 ►1/4se,)ak53 TIME PATIENT ARRIVED IN SUITE cp3q 4: PATIENT IN R

TIME. :6143 14 5. PREOPERATIVE EMOTIONAL STATUS

LI CALM ANXIOUS ❑ EXCITED ❑ CRYING ❑ ANGRY

COMMENTS: 31 \i t, (la,.

r)CUMENT ,cy is the office of The Surgeon General.

RD REVIEWpiln PROCEDURE

11] WITHDRAWN ❑ OTHER (Specify)

MEDICAL RECORD( r

NUMBER ,9c-cyr. g

__ _....... ._ --......-

'; ASSIGNED SPC -- --RELIEF SCRUB

E

. SCRUB

ASSIGNED c RELIEF CIRCULATOR ..____ - ... . __CIRCULATOR

IN.1.., 7. POSITION.ANQ.ROSif ION • 1-:-.,.4 id ifb.^ 6,..-z-v- c• (I-I ,..1) , .)

10--S S. (./J5- 1 @5' SIJ II 0-1 bl•c LiNisa'....b‘'fl• • COMMENTS:

1'11)1 A ( Ap, O. ..sin esj-4.1. i.74.9.11 di of • Pcit\l'!.', i.... (!tY*,Ovel C ■0 •-": ..,1) ,..., WI-S OsiN 43 (sin boa i e m., ‘ UPINE LITHOTOMY PRONE U KRASKE. LATERAL: LEFT SIDE UP 5CRIGHT SIDE UP

- - -•-------. 8. SKIN PREPARATION

HAIR REMOVAL U YES pN • PREP OLUTION(Specify) 62f0,-5,7,ft„b ipao. DONE BY: M OR • NURSING UNIT SITE Hoi eiwttoi-U BY WHOM: J1}0,7

COMMENTS: -_-__--_—__ COMMENTS: (IQ ec.,,,,;,,,JJ \P

METHOD: • DEPILATORY Il RAZOR SITE: iiri7t--C) +06 BY WHOM: Olin --1 CLIP ..._-__..—__ L4)

9. LOCATION OF EXTERNAL DEVICES

...._ 1. :Mat - - r•I . -

_ i-•

--nu"."1"11.MINIMI11111.-- _

0

...

..,.,.•....

LEGEND X Ground ad -- Saf = = = Tour 114 niquet .• .. ----- l'A C = Correct I = Incorrect `-'5-ii4--.:.12 ei>.)a • .

Needle Sharp NI Yes AIM . c C.

10.COUNTS Other•• Count .. ,• Cciiint SCRUB First Closing Final Closing

Sponge nilYes C

---

Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)

Instrument MSZERAEWAIIIIIIIIESEII__. c_ . •-...• Other El' Yes ►1_IEMIIIIIIIIIPAIIIIIIIIIVAIIIIIIIIIIPw PP"

Illti

11. PATIENT IDENTI !CATION (For typed or written entries giv • . 12. ELECTROSURGERY DEVICE(S (ESU) VI YES • NO

.....:-_ ma

' yeaSU NO: g? (s 1b93

--lam) LOT NO: ...--,

GROUND PAD: BRAND 04(1 e kb LOT NO: -1353 ..•,-:- ".'ID:7,ESI.lNO: , .. .

.•- --GROUND PAD: BRAND . .,-

MI BIPOLAR NO:

DA FORM 5179-1, OCT 87 REPLACES rut Frirmn 5170_1 rrcen, r.r......... ......-...- OBSOLETE. _ USAPA V1.00

MEDCOM - 23550

• IS OBSOLETE.

DOD-037128

ACLU-RDI 1681 p.110

13. P _ _ _, „....., /

,/ ,•.“-, it r to INAPilt: IU NUMBEr IUFAC" lER

14 - -,, MEDICATIONS/ORDERS', = &- . IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES NO MEDICATIONS/SOLUTION DOSAGE TIME : METHOD PREPARED BY GIVEN BY

40UND IRRIGATION C)fizz.YES • NO, TYPE(S): Vcron

!OTHER ORDERS TIME CARRIED OUT BY

.,,

;PHYSICIAN'S . SIGNATURE

. . 15. X-RAY IN OPERATING ROOM

_ - _, IF YES, SITE

YES 1111 NO .(6 16. ':' LABORATORY SPECIMENS SPECIMEN IS)

YES • NO

FROZEN SECTION (FF

NAME .. _ _ ____ ___.. NAME r,

YES • NOFA

NAME NAME

CULTURE (C) YES / NO crcl

NAME

___ NAME

NAME NAME NAME

NAME NAME 18. DRESSING/IMMOBILIZATION (Specify)

PO Ct Tle - - - --- - 17. TUBES, DRAINS/PACKING YES yn NO / TYPE/SIZE i.re. 2. .

SITE 1. ft

K ,,t

J01-1- ;1‘.1 2. 3. - . ---_.

19. ADDITION T N

si r ta--m- Dr

_ ... . .

20. OPERATION(S) PERFORMED

ctIb )1) ho 'D el l / _5-d h 0 trN'T f _TS D 61j' -.P. Bvi4AL / -j ( D ed6f6-P -frit L

21. N, PATIENT TRANSFERRED TO ti„ % „...-

C I TIME__

'' lA 1 C176-1 22. REGISTERED

METHOD I ,

1-14 NURSE SIGNATU

REVERSE OF DA FORM 5179-1, OCT 87 USAPA V1.00

MEDCOM - 23551

DOD-037129

ACLU-RDI 1681 p.111

ke) ti tt) INTRAOPERATIVF - 1CUMENT

MEDICAL RECORD .-- For use of this form, see AR 40-407, the proponi is the office of The Surgeon General.

1. PATIENT TR • 'ORTED TO OPERA1IN .it.)0M.

i lam, BY

2. PATIENT IDENTIFIED . I ' ND PROCEDURE

VERIFIED BY Ala VIA. di

-- '7 • 3. DATE e TIME PATIENT ARRIVED IN SUITE

? 1P/01/-0 2 l 04/C--- 4.' PATIENT IN ROOM

TIME : / 0 11.5---- NUMBER ....-,....)... - 3 5. PREOPERATIVE EMOTIONAL STATUS

CALM

COMMENTS: /1)101

ANXIOUS • II EXCITED • CRYING • ANGRY • WITHDRAWN • OTHER (Specify)

1.

6. NURSING PERSONNEL

• ASSIGNED SCRUB

9 //›.; — . — "RELIEF SCRUB

ASSIGNED CIRCULATOR

CZAIIIIIW:__r- 66-t RELIEF __CIRCULATOR

ilq .1;. ..__ . _...... . ..

0,-, -Pot 7,-; doe, _,,,(4 Fs ..1f!-- , 4T--/ ,9;0-5 . atm , fr/r15 (7) -P

1.1

5:e(2A-4,-et i pe LEFT, SIDE y P $ RIGHT SIDE OP

P-r, 1 .5 1a.a k., 1Qe___J-60.e. /c4, 3-€7/ eso- r 7 k:A

. t . . ) 0 3 efr .15 --e.C:A-t ,-"eY, 4;30,7 3qcji CiSe

r, __J- AI 7. POSITION AND PQSITIQNAL A.45 (Specify/ .51-012 d o z- peo. • ..g, .grel _.hk '''S'Li pv.Q... *or- .5.. rry31 n-1-- i---r Le, ...G,-(111—. e,d,,5 A

UP NE LITHOT Y WO KRASKEi• „, LATERAL: 40 ' cq r rv-‘. c".e/ e- C C "'",•-- 9 - . $ Iii - ,9 . 5- pi 1(0 i.c.) ci

-.e " 8N4 f r 0 (ls- - eo,_ t -I-, )C4. --, _ci I 1.cc,,-- " -..1:<eci r 1:k pi I Icy L(1 ,Cyn e z 0 renr=)o-clr C pi OW or, ny -i- /N6 -6'4-J-el° 0+79, 110 Crre,t, 4- I Cily RI I D,r) vz.t.e.,1+- etc) , 4642,4<1 PREPARATION

HAIR REMOVAL Ri YES/OR DEPILATORY CLIP

Yln cre

• NO

UNIT

etalk e p •

•• "--PREP SO1_UTION (Specify) B.4-eLel, i'i r SITE:13,1At KW(' I -Thi a.45 BY WHOM: api

IT • i-gKr°1 a BY WHOM: 1-t p t- i..1--Pfd, ' , . bia ,r,..,,,

COMMENTS: 0 pc° , • C-3 .-1- SO/ l %a', S' '1 d kJ

DONE BY: •

d

U NURSING METHOD: • ► RAZOR By

Slik4-140-a-.4.1

ae ..4,144.4.--A" COMMENTS. 11° n1 c_LA .-1---, 9. LOCATION OF EXTERNAL

•

d Pad

DEVICES

t.,,,..

.-7/Safety-S ,

ANNixbutz...aw,.; „......--, .- -4 : -, a

,--..N..-4-44 '11",'"IIN

fr

44 Akatb...-gew'

Alikt N1:1114

I fb I

--- I... ."....

- ,., ,•

LEGEND lecclun

111117Aro - • ■• , I 16-. ...;:-..--■---

, Clef ' f il` 7 .--- -: -::.-:- (Of tr- = = = Tourniquet

10. COUNTS

Sponge -% Needle Sharp m Instrument ❑

Other U

=II cm Yes Yes

- --

Grade•

;I.i

A

__

MI

For

.

C = Cor ect I = Incorrect

ME:IMMO/AIM

E3F4111111/1/Aill

Date;

b(-1/ -/-1

‘ Mil IA Other• •

typed or Hospital

MEIWAIMIMIIMPIP'

First Closin Count .. ∎ ..

written entries or Medical

11141■111111111111W11111111121i Final Closing Count .SCRUB

,.....

CIRCULAT• : ...

give: Facility;)

......:,.;,1,4..,.:.;-. -

12. ELECTROSURGERY DEVICE(S) (ESU)

ESU NO: K ri3 (c12..aci_r

_„------ , Er YES • NO 11. PATIENT IDENTIFICATION

Name - Last, first, middle;

411111Q62')

71‘101,-- 0 3 - - -- - - - -- -

GROUND PAD: BRAND kick-,t tek rak- LOT NO: , 5-76 -4 E,, -2ed if-ti -, .; ESZSU NO:

•••- -GROUND PAD:

. BIPOLAR NO:

BRAND

LOT NO:

- 1,

REPLACES DA FORM 5179-1 (TESTI, DEC 82, WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 23552

DOD-037130

ACLU-RDI 1681 p.112

13. PROSTHESIS, IMPLANTS ❑ iiiVNO IF YES NAME: ID NUMBER; II TURER

14.- - - - ,,, --111EDICATIONS/ORDERS L .;,. ' .',-,- ', .-TAWI:-' '- ,

IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES ❑ NO Nti MEDICATIONS/SOLUTION DOSAGE TIME • METHOD PREPARED BY ( GIVEN BY

. ..

i

WOUND IRRIGATION ES NO, TYPEIS):

,OTHER ORDERS TIME CARRIED OUT BY


- - - .- I ^ r ,,. . •- _

15. X-RAY IN OPERATIN Rt,sM IF YES, SITE YES ❑ NO ri.- ,

16. :".LABORATORY SPECIMENS SPECIMEN (S)

NO

... AME ._

YES • FROZEN SECTION (F )

NO

NAME NAME YES II CULTURE (C)

NO

NAME _ ,_. _ ___ - - —

NAME YES •

NAME NAME NAME

NAME NAME

/_ 18. DRESSING/IMM BILIZATION (Specify) , ,

K-clit-e-.6 got ls1 IC k k K fl(-4 -4s 4-e pciols, acc -1-0 t x _

\\(._ A-mp--e_ -4-0 134A-71--izi

17. TUBES, DRAINS/PACKING YES NO TYPE/SIZE 1.4_0yleK 6

/VaC12- 2.

.„.. .

SITE 1. 31441-aek .t--

bielaVtThillt CV/G

/- 2. ■,

19. ADDITIONAL INFORMATION cue_ __Iir

cut, t t.4 ; it).- -- -esq- /1.

Frm\e_ ,pa ct s , k pre -op- CDL zs -I- -op CD-I-- i

IDA 5-1?? p cev le...AA ss 17 fr-L...,_. 20. OPERATIONIS) PERFORMED

LA.)0,,st.A1 6.A- ca-- 5.e(...A.e.0,A. c7.1.4.,4„.(..s:. . Qi.., -..--...A.. -14NI'k_ L,..$ 0446,4tr -

21. PAT ENT TRANSFERRED TO

Ar-.14. TIME METHOD

' . R ISTE -- ......._.

CST/ /(111✓

MEDCOM - 23553

USAPA V1.00

DOD-037131

ACLU-RDI 1681 p.113

b \ MEDICAL RECORD E INTRAOPERATIVE r .00UMENT

For use of this form, see AR 40-407, the prof :y is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPriA, .‘1G hjOM

VIA 11111b. BY Ito es-th , 2. PATIENT WED AND PROCEDURE

VERIFIED BY CPT IAA) 3. DATE TIME PATIENT ARRIVED IN SUITE

'/1 AJOV 03 --- 4.- PATIENT I

TIME:1,051• NUMBER


U CALM 11 ANXIOUS • EXCITED U CRYING ❑ ANGRY • WITHDRAWN gri OTHER (Specify)

COMMENTS: -li red -fibm .., arnb. LL stai, pi crithhAs 6. NURSING PERSONNEL

: ASSIGNED SCRUB

PFC ..._ _.. --'-REL1EF SCRUB

ASSIGNEDCIRCULATOR --1111k4--C - . . .- -----

_, ..., RELIEF ..C.IFtCULATOR

alirin0-154)

7. POSITION AND POSITIONAL AIDS (Specify) - •--- .. ,.."-_...,

PI SUPINE • LITHOTOMY ❑ PRONE • KRASKE

Bean back .-kr posi-horay . • COMMENTS: ft. s, • t i ' • - 1,,

1) rIllaos klitanItqc au llny( roll ) pitusto= -eitown

LATERAL: •

3afe Irms

LEFT SIDE UP 6 RIGHT SIDE UP

81rap etcYos 1.95 I [at. piPion

? SKIN ) 8 . PREPARATION

HAIR REMOVAL ❑ YES g NO ' '

DONE BY: U OR • NURSING UNIT

METHOD: M DEPILATORY U RAZOR

• CLIP

COMMENTS: .

PREP SOLUTION (Specify)beAd(nt 5C SITE: ja. 112C./ BY WHO

',.' SITE: Leili BY WHOM.

-,T•gutto 6 Cdm " NTS: 0 poo)inol of .-Flutt

9. LOCATION OF EXTERNAL DEVICES J

A ifei,M59502•74,.. 6IPL:' At, . ,

• / ,7--------------4(Tisaw."11"---v-m -4=0ff)74/11.7 7 J .-=s - , ------ , . ....•,..

.- .

LEGEND X Ground Pad -- Safety Strap = = = Tourniquet ---..,--......-

10. COUNTS

C = Correct

Other' • First Closing Count .. !,:.

= Incorrect /.,

Final Closing . Count SCRUB CIRCULATOR

Sponge Eg

Needle Sharp Z

Ye

Yes

o o I 0

0

Z 7 7 7

. V

IIIAMIIIIIIIIIIMIr Instrument ❑

Other •

Yes

Yes WMIIIMMIIIIIIVAIII.__ _.

11. PATIENT IDENTIFICATION For typed or written entries give: Name - Last, first, middle; Grade Date; Hospital or Medical Facility;) in

A .

12.

•

ELECTROSURGERY DEVICE(S) (ESU) ❑ YES V NO

ESU NO: 30130 GROUND PAD: BRAND

----.:— LOT NO: ,_ :ÌLSESIJ NO:

_ • - -GROUND PAD: BRAND

LOT NO:

U BIPOLAR NO:

DA FORM 5179-1, OCT 87

REPLACES DA FORM 5179-1 ITESTI, DEC.82. WHICH IS OBSOLETE. USAPA V1.00

MEDCOM - 23554

DOD-037132

ACLU-RDI 1681 p.114

■ o. r r iv., i n coio, iivirLHIN I 3 Li T L.. A !Nu IF YES NAME: ID NUMBER; A : IER

1..

14. ,; -. 'MEDICATIONS/ORDERS ;TtcW-1 i IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY. ANESTHESIA) YES NO 10

MEDICATIONS/SOLUTION DOSAGE TIME METHOD PREPARED BY ( GIVEN BY

-MOUND IRRIGATION (211 YES IN NO TYPE(S):

Acl ph) NS ..,

OTHER ORDERS TIME CARRIED OUT BY

Q., ...,.....,--

,PHYSICI

15. X-R.

YES

.. _ IF YES, SITE

II NO o:IiI 1 ::;

16. :LABORATORY SPECIMENS SPECIMEN (S)

YES ❑ NO cm NAME

--:- L=..------- NAME

FROZEN SECTION (FS)

YES U NO ki NAME NAME

CULTURE (C)

YES • NO

NAME NAME

NAME NAME NAME

NAME NAME

_ — —

18. DRESSING/IMMOBILIZATI

FirA r-E ON

nak

(Specify)

13J bi- tlerY.5 AND larli Le 6talcd6 4 Y 4

Ace' la. pt

17. TUBES, DRAINS/PACKING YES El NO IN TYPE/SIZE 1..,/ „.

-3/8 Pkrivose 2

1" an rose, .

1 NarctsQ. ki . Eitti ocks

SITE

R-4.- -fttiqh

.

LI . -kick) 19. ADDITION MA ON

Sul. Anesth; Sar 4i0

. _

AM ) jpe : Ceoeval

01 e9 In pbct PTA 20. OPERATION(S), PERFORMED f

1 , T. 7D 1 . 1, , U-. Legs wl elostwe of wouods

2.1 4,1) e4. 13cd-i-bcks lb) C:fo&ai'L Of wounds 21. PATIENT TRANSFERRED TO

Nal TIME

13 23

METHOD, ,

Stretchier 22 ATUR E

OPF/A 1

/

1/ In a1 \ .4-,,,/ REV , OCT 87

MEDCOM - 23555

USAPA VI .00

DOD-037133

ACLU-RDI 1681 p.115

i -STAT CREA

Pt :1111111. -4

Pi Name:

Crea 0.9 mg/dL

Sample Type_:

08MOV03 08:19

Oper:11111 \-2)(-2'

Physician:

SPr# 42011

Ver: JANSO4GA CLEW A33

i -STAT'EC8+

Le • Pt Name:

Glu 190 mA/dL .

BUN 10 mq/dL

Na 13" , mmol/L

4.1 mmol/L

Cl 1 -,J7 mmol/L

TCO2 zc mmol/L

AnGap 15 mmol/L

Hrt 34 %PCV

Hb* 12 A/dL

*via Hct

pH 7.325

pr:n2 39.2 mmHg

HCO3 20 mmol/L

BEecf -e

Sample Type_:

08NOV03 08:14

oper:IIIIIII, , )

Pt hysician:

Ser# 42015

Ver: JANSO4GR CLEW A93

i - STAT EGG+

Pt:

Pt Name:

Na 135 mmol/L

4.1 mmol/L

TCO2 24 mmol/L

ftct 35 PCV

Hb* 12 g/dL

*via Hct

At 37C

pH 7.337

PCO2 41.G mmHg

P02 114 mmHg

HCO3 22 mmol/L

BEecf -4 mmol/L

s02* 98 %

*calculated

At Patient Temp

PH 7.334

PCO2 42.1 mmHg

P02 115 mmHg

Patient Temp: 99.0F

Sample Type_: ART

08NOV03 08:12

°per: 111111111 Physician: = /`~~°12

Ser# 42011

Ver: JANSO4GA r!FH A93

MEDCOM - 23556

DOD-037134 ACLU-RDI 1681 p.116

Negative Malaria

(? c

LABORATORY RESULT FORM (Subject to the Privacy Act of 1974)

SS

REF RANGE RESULT REF RANGE RESULT REF. RANGE Color Negative

11101111--- 08-11-03 Hgt WB 08:52 Patient Hct Was

HNC 15.9 H :10'3AL 4.5 10.5 MC NBC 4.23 x10"6/tiL 4.00 6.00 HO 12.4 g/c0. 11.0 18.0

Plt Hit 38.6 1 35.0 . 60.0 KV 91.1 fL 80.0 99.9

1,-r y 101 29.2 pg 27.0 31.0 111C 32.1 L g/d. 33.0 37.0 Plt 281. 110"3/111 150. 450. LY1 9.4 *I. 1 20.5 51.1

Seg LYN 1.5 * x1083/01. 1.2 3.4

Negative

Negative

Negative

Negative Gram Stain Occ BEd

Source

IVficrobiology

Negative

Negative H. pylori Negative

Micro Parasites

0.2-1.0

Negative

Spun Hematocrit

42-52% (M) 37-47% (F)

CSF , . - . Blood Bank ,

Sed Rate . ,

Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other Directigen Negative ABO/Rh 1

'Coagulation : Studies:: ' ' ' ::::' ; :: .. .- •

:' .. - - : : .. . Blood Bank Unit Crossmatch (MUST SUBMITSr518 WITH EVERY wir OF BLOOD

TEST RESULT REF. RANGE UNIT TYPE CROSS.(114TCH PT 9.8-13.6 secs

APTT 21-34 secs

D dimer <20 ughnl

FDP 10 uglail

REMARKS:

D Dfl D'T-E'T% DJ . •-■ - "•-•-• - - - _

RBC Morph

Negative

Negative

•

MEDCOM - 23557

DOD-037135

ACLU-RDI 1681 p.117

n t, 1

I LAST, FIRST„M

1-2 (.1) -(A TT\ LE

LABORATORY RESULT FORM (Subiect tc- the Frivaci- Act. F

SS' -

RESULT

RAPIDPOINT COAG ANALYZER V4.54 SERIAL 4005485 11/08/03 03:20

Pat ient ID: lip Test Name Test Result:. 14.1 sec_ Ratio = 1.2 Cd1culated INR = 1.26 ..,ample Type:citrated Nh. blood ;est Date :11/08/03 les; Time :03:16 La; t i (4 :080201 Opeldtor : JACKSON

;;APIOPOIN1 COA.1 ANAHLER V4.54 SERIAL 4005485 11/08/03 02:22

Pat lent IT.) 1243 rtz:1- Name. :OTT

Rez,ult:= 21.5 :;ec. 4,4kESOLI OUT OF RANGE.4:“

Sample Type:citrated wri. blood Test Ddto '11/08/03 Test Lmi'

Card rut -1 .

Opelator )o

-- - 1 - -- - I -

zf.'olor 1 N./. A

-F-T l

C I 11 N'A 1

Gid

1 CC:

i Ncgativc

Bili Ncsztiyc

; Kct 1

Ncgitivc

'SC 1 1.030 NIA

Bid I I Negative

P ' ., A . N/A .

Prot

Urob

Nit

Lcuk

HCG

N141.1.ivc

. . .

Cell Count

Dircctigcn

\t›

INkgplivc

0.2 - 1.0

Negatirc

Negative

11/11111 WB

08-11-03 03:31

Patient Liiits

IBC 37.5 H x10"3/111 4.5 10.5 RBC 4.01 110"6/uL 4.00 6.00 Hgb 11.9 VA. 11.0 18.0 Hct 31.4 Z 35.0 60.0 HD 93.3 fL 80.0 99.9 tCH 29.7 pg 27.0 31.0 MC 31.8 L g/cR. 33.0 37.0 Plt 464. H x101/uL 150. 450. tyz 11.9 •1 Z 20.5 51.1 LYB 4.5 * x101/u1 1.2 14

CROSS:I.L1TCH

I Ncptivc 1.4.BO/Rh I

Bloo:d..B.s -ak Unit Crossmiitch . (NIUST,SUBNUT Sr 518 WITH EVERY f..)7.̀/TT Or. BLOOD • .

RE Q LrESTED) UNIT TIPE

21 -3 4

<20 =

D

FD:

REMARKS:

P_EP-ORTED BY:

<:0

DATE: LAB 137

MEDCOM - 23558

DOD-037136

ACLU-RDI 1681 p.118

73-118

7-22

8.0-10.3 ria al

0.6-1.2 ruE ,J1

128-145 mmol/1

3.3 -4.7 rurri.11,1

1 93-108 mmol/1

118-33 mroobl

-cOloylli.e2ePdnel

TfC (42 -FS

Ward,'S eztictivvi

LAST, FLRST,

TEST

Na

Cl

K

pH

PC 02

P02

TCO2

HCO3

s02

BEecf

An Gap

Ca

BUN

GLU

Creat

Hct

Pgb

TEST RESULT

138-146 m.mol.c1..

98-109 Eamon

7.31-7.45

35-45 mmHg (Ln) 41-51 mmHz (vool 80-105 mmHg a.rt) NIA (veul 23-27 mmoV1._ (&i1 24-29 mrnol/L (vca) 22-26 mmoVL (art) 23-28 mruoVL (vca)

95-98%

(-2) — (+3) romoilL 10-20 mmol/L

1.12-1.32 mmol/L

8-26 rr,g/cil

70-105 med1

0.7-1.5 mg/d.1

38-51% PCV

12-17 g/dl

REF. RANGE

Drug of Abusc

REQ

RESULT PP.F. R4.NGE

BUN

GLU

TP

GLU BUN CRE

CHOL CK NA+ K+

GLU CL-tCO2

CRE

BUN

CA"-

TEST PICCOLO 08/11/03 • 03:16

ALB REFERENCE RANGE: MALE ALP PATIENT #: ALT METLYTE 8

DISC LOT OPER #: 269 SERIAL #: AST

AMY

TES:

1 -7.7:72== PICCOLO ----- -- 08/11/03 09:10 AM

- REFERENCE RANGE: MALE INST OC: OK CHEM OC: OK PATIENT #: 1111111) _ ck _ HEM 0 , LIP 3+, ICT 0 LIVER PANEL /078-- DISC LOT #: 3154AA7 OPER #1111111.1.,.... DR #: 000 SERIAL #: \:>(''' 0000100684

240* 73-118 MG/DL

11 7-22 MG/}DL

1.2 0.6-1.2 MG/DL 711* 39-380 U/L 129 128-145 MMOVL 3.4 3.3-4.7 MMOVL 99 98-108 MMOVL 2? 18-33 MMOVL

CITEINILSTI2YRE(SULTFOR.411 (Subject .to the ?riva!:).Azt of 1974)

1 2,A ; T1.1\ 13 . I_ 1,1711 "62910 6 (C-e) -

co tetabolieTaaer... -.:- :.---.-

RESULT 1 REF. ,R..-INGE

3151AA4 DR #: 000

0000100494

tCO 2

NA-

CRE

CK

CL'

ALB 3.1* 3.3-5.5 G/DL ALP 89* 26-84 ALT 41 10-47 AMY 36 14-97 U/L AST 42* 11-38 U/L TBIL 1.0 0.2-1.6 MG/DL (3(3T 51 5-65 U/L TP 6.3* 6.4 -8.1 G/DL

INST GC:- OK CHEM OC: OK HEM 1+, LIP 3+, ICT 0

TBIL

tCO 2

P.I.I'ORTED BY: DATE:

I LAB ro NO.:

MEDCOM - 23559

DOD-037137

ACLU-RDI 1681 p.119


AN

ES

TH

ET

IC A

GE

NTS

AN

D D

RU

GS

I

CO

NT

INU

OU

S/R

EPE

AT

ED

DR

UG

S

SP

EC

IFY

UN

ITS

- M

G/M

CG

/ML

, 'I

" =

CO

NS

TA

NT

INFU

SIO

N

DRUG (Units) TOTALS TOTAL EBL

, (,)-) " , .›,,, ,a,-,0 D-o-0

--,-

P-€."-----Ri"1 L. ( c` C..- ,

I

1,7 t Sp <,... TOTAL URINE

4) 05-t$ t,-,-.1•R- /gal r),-e) . .><

3-117,5 lap, .-N .&-)- ntul?"11°Q

) (

0'12(

VOLAT AGENT

ge`c"4" % del C i b / --- /----. FLUIDS - SUMMARY

% e.t. CRYSTALLOID-

--36ri, -3?.' AIR L/Min

N20 L/Min

q

- LIC.Q......

02 L/Min a— — ---_ BLOOD - .\.......„............ SINGLE DOSE DRUGS-MARK ON GRID _,„

WITH NUMBERS & ENTER IN REMARKS

FLU

IDS

LINE site LA Itfvb gg War -• -., ).-- fah

ir• 1.• (N)

REMARKS

Code drugs with numbers, events with Millers

"a-k..k ..,-. erk.;. -1-,-. cyt - .........,--.13 do, se S.

;n,"6-,S. i."- Irk \SSS. . No,

(-)a.. Sr-Q-str....yz&k 1 c

E,-.1 e_s. l'y %I? stj MT- 11 (off — 5-1

ate, N.<3.,„__

S-Ic . C.,751 C/b..-

C1-11--40-$4 ; 66>\

""Rtia=f3re*, -

-C).-■ e 5.2 .

sc.. ,I_/ MI- iico/k"

0 0 55_

Ltn-gyro ,..-lcr."-e

-ne-A-.--ivni-T .

RE OVERY AT

❑ Warmed t9.,i4) A. La-., .9.5A) /16 xd- t_ ❑ Warmed

❑ Warmed

6 Gsp

EST BLOOD LOSS ..--C LOSSES

UR NE --)4.- .

PHYS STATUS TIME ♦opo oCo- 663" 1c. 3 4 5 Ir.,...)

SYMBOLS: BODY WEIGH : 220 .

..,/ 50 1) BP by cuff

V

A Heart rate -

• Resp rate

BR (transduced)

_L T

TOURNIQUET

T -4/

ANES- X-X PROC-0_,25

. L m :

200 ,

HEMATOCRIT:

1. 'C 31• 14 180 .

INITIAL DATA: 160 '

, BP- 051 C:i5

140 , F—I--

/ II II II

120 ERNI/111E1MM I into ipzer.Artgliffah• HR -

6 ' 100 SEI . Mr= IMMUMMA' DS , . . . NUM . .

EQUIP C ECK 80 . OK? - Y N 60 411P . MN PATENT RECHECK PA EMPAN,WittArAvA ma OK for PROCEDURE? \

TIME-

40 -1111FIEWAVIAM1111111111311MMIll THAPAILI111111111111 .

2.1111.1111....011. 20 .. ,

,,

i VT-ml 9 s-,.., 1.) .4 i f a 4s t., n

il f - breaths/min (O R -K Peak )nf ores / PEEP a) 42_

RI MODE - S(pon). ssist). CIon) M WM %./ C‘i CA/ —

BP /Auto Cuff ET CO2 (torr) 3 -= / -“,- IESINIEVALIMIIM Nrap Specify) BPloth F102 (Frac or %) .i.,-( M - S3- ., 4 • 8 58• MN

OTHER ART line Sp02 (%I i o...2 6.,J too fa., /V itso 1.153 CONDITION:

RESP- ).., Sp02- -53g

BP - HR - ), ,

Steth- PC/ES ECG S A 5- Si 5/7 ., . i 11-

Gas analyzer TEMP-site'

LC

7

N-M Block (T/4) Eja 411( li y

MN Er ,

ANESTHESIA / PROCEDURE' TIMES

co Start Room End

MI CSt NE Warming blkt

Cony warmer Ready Begin End Murk with letters a syn bots, EVENTS_.... — LL — explain under REMARKS Position - 02C•6 : ,111 C So 4. - S.L.

PROCEDURES and CPT Codes:

CAolvOgivg,a ,, _Dr/3 &a-n-0,4s., criii (.41- -tATII,GIA ANESTHETIC TECHNIQUES: Describe block technique under Remarks

CE- 771- AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

6-r :-.1 fhok-lr) * Ec-5 6-t- ev-'')P3= 65 (-fit` -colfi. 21 ,— (4/1 C-N--) 6(74_.D,z5u,„ .KI,

PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Mpclical facility

jr LI 1-- aill

SURGEONS: PROCEDURE 4,1 LOCATION: C̀ .11- `-'9--- DATE:__, \r0 PAGE g OF

DA FORM 7389, FEB 1998 MEDCOM - 23560 COPY 3 - ANESTHESIA DEPARTMENT

USAPA V1.00

DOD-037138

ACLU-RDI 1681 p.120


.PRO.O.:::: :si::MJnit.$) TOTALS - TVP.44::: ..c.e.,0- 4,,,,ik. 4)-3 ) mobcre 1 ($15 1\-t.

(I, e)0\ /rep twi ) NtY 1 ac. I pig

fs-t.m.K (,),- ) 1 VD j tikViiiiiiti Ins-c.,,,er", I sbaz I

I 1 004 I ) . .. . . . . .

..,,votAT::: : :A0E611.::::

I Su % del WNW ti:S.UMW.01 % e.t. CRYSTALLOID-

1 OO AIR L/Min

N20 L/Min COLLOID-

L/Min lex --.1.--1- .4-3) SINGLE WITH NUMBERS

02 DOSE DRUGS-MARK ON GRIL ♦

& ENTER IN REMARKS

BLOOD-

LINE site ❑ Warmed REMARKS:,::ii: ::n::::i.: ::::

$t- ❑ Warmed 1 ---4---,----0------, Code drugs with numbers, events with tethers

Q tr) , utn.c....--i- 1.4.,4•....

12.posss.(41.L..."-s-4,-; .

Stu', el.,' Inu) ,

I ..-ay 4,0011.. b\iLlr.t -, A4-r--4 eyvar-oL

A sc. -cuttt. ❑ Warmed ...---,----1...-..........-,

❑ Warmed

Ad-Ogts: EST BLOOD LOSS

::::.:::::::::::::::.::: URINE -

:'PertS:iSTATLIS: TIME +NI' C) • x. • ti• ), • 13

:°' :1,?-1:FR:q:f. :;

BP by cult

V A

Heart rate

• Resp rate

BR (transduced)

41

TOURNIQUET

ANES- X-X

PROC-eizi

.

11001'.:41:00.k1V

t C3600 LB

zzo ' izsusr.sc -1-1,-4(- pta..cli T tiv-e-N-t4

r•--•?(J—.... ,, 0 Co*PLate-rke•-1 ie

200

: , HEM4179GRIT::: 180

-1.1.-- 1.

rei 4.,...... vf-vt .1C 1 fo

-ilt.4.P7jA4::PATI.A:':!. 160

et* is 1-1-b p-trai.kA

140 V c.N. V 3.2o.-e-La..rs of....14-,,t 1 BP-

1710 (t V

----V . ... v v

120 V V N1 Cbrfr isnr.-aa Crvio.-4-4

HR - I it.

.

Ni V V ♦

V NI • A • • ... - %-c1, ta.m#010.1411. 100 to y • • • • • • . . •

80 To Eitta t , v.--p.,--4- ;:EQUIR.::CHECV;

0 K 7 - C.3 N A A, "A • 60 ''''/%,

AAA z1A±A_A A f•

- . ... . . ... . . .... . . F9kTIPOT:likctIgcK T —/1/

,

OA for PROCEDURE? Y

TIME- tor!

40

20

6y_____, . o ii3. i) VT - ml epeo Pa eat. Elio 1-000so GOO Co tit) b T•1100iZ6 3 /

f - breaths/min - 1 4-1 12• is t-z 8 e 1 to >tv

•roLa.A., 8.41 Peak Mt pres / PEEP Zel 21 2.1 21 - '

MODE - Sfponl. A(ssist), Cloo) S C C. C C CIA S .1. tigOdYtiiO411 1310 Cep/Auto Cuff )QET CO2 (torr) - 74 24 3e. il IN S/ 44 PAC ICU Specify)

BP/oth aF102 (Frac or %) 8J0 11 /I 'II -11 II -re, -to ART line Sp02 (%) qi (CSD lib lab I an tub lab Io? OTHER

Steth• PC/ES k:ECG ST Sr SR, s•t_ Sn_ sr 5T tr CONDITION: V-...4(4,

Gas analyzer >zoTEMP-site t - al •eo 17.7 11--r- STT 374, 27.1 37•e REV- I, Le 5902- ilElk%

N-M Block (T/41 BP HR- 1U•2 01451!g.$*::■.!:imP...FL.- 1 ,•rimes.:::,.,:::::::::::::,,,,,:::::::::::%.:::::::::,:.:::::—.

Start Room End

Warming bIkt 10q0 10 1(4 11 10

Cony warmer Ready Begin End Mark with lerrors & symbols, EV ENTS__.® t que 0., 606.441 . c

S.4. 14 .

esplainoneter REMARKS Position c Q•..r.kiLe.-04 . pr- Q --tmr.'r 1050 77z.s- 12.1-o PROCEDURES and CPT Codes:

I -4- 12:) Las / 601-1..*#p CA_S

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

GSA- A

AIRWAY MANAGEMENT: Intubation route, blade, technique, comments

ile•c) Gem Z; 4..t..:,,, . al-r #-Ivtle. 3 PATIENT IDENTIFICATION: Typed or written entries: Name, Grade/Rate,

Medical facility

ePt.),) SURGEONS: PROCEDURE LOCATION: DATE:

A ANESTHETISTS: OS kJeu 0.3

MEDCOM - 23561 PAGE 1 OF i

not CelIntRA -soork CCO 1C1C10 r^110V i DA TICMT•C RACrtIP AI DCrf1011

/1.CPDA %/I /VI

DOD-037139

ACLU-RDI 1681 p.121

MEDICAL RECORD - ANESTHESIA For use of this form, see AR 40.66; the proponent agency is the OTSG

.::.:SOlf11:

3;;ON

VI,S

IN3

Dr:01.14

111$::

CO

NT

INU

OU

S!R

EP

EA

TE

D D

RU

GS

S

PE

CIF

Y U

NIT

S -

MG

/MC

G/M

L,

'I' =

CO

NS

TA

NT

INF

US

ION

...1301.1 .......................... :,ILInit0.: TOTALS TOTAL :

Pi40v-c7_ (# ) --)17 .. -2-ef* ,•-•'`.. I in- Ix2 q°

a -- l c4- ::I Ii4:::jAiNC -Itir-IL 1 cc ) lhoLpiPI/vg- (/ ) 9 'A- 2_1_.

(d) ( )

L5' v a % del citA.I::::-Ic-N,e.. 1,j- .'c--- , — .' i. a —t,2 AGENT % e.t. CRYSTALLOID-

AIR L/Min

N20 LlMin

— ' . a LLOID-

BLOOD- 02 L/Min - VERMIZMIIIMINEIIMILI

SINGLE DOSE DRUGS-MARK ON GRID.* WITH NUMBERS IS ENTER IN REMARKS _.........—..,

LINE site Lii (4.1001-C.Allamed( 1-

g 0 Warmed Code drugs with numbers, events with !enters

fir,.....1...-W 4 4-0 'TO cY2-2t a. An...At- 3

ill C--tc--•-‘ E-14'i9

Z •:_s ID Warmed

0 Warmed

tii.: gig EST BLOOD LOSS

UR NE -

.4TN1114::::; . E _.. TIME '-' TIME

,, •ilBttii 'T •

220

KG LB

BP by cuff

V A

Heart rate

• Resp rate

BR (transduced)

+

TOURNIQUET

T —/1/

ANES- XX PROC-C>.0

200 —

.. ,

•:::',HPYYIPOPIT.:., 180

160

INRIW.Prk.r.k . BP- Di (-1.< 140

/ 120 HR-

1:::tQL/W.i 6

100

MIT'XIIIMIIIPIIPIIIMINPMEIMMEIPAP IIMIWAILIVANIMENVONSFAIONTflarJ i7iro misivisamingram,

80

OK?- Y NI 60

PATIENT R ECHECK 111111111111111GLIENENIIIIIIIMINrinAmmirm A Or( for PROCEDURE?

TIME-

40 Lim. IIMITirALTAATATINFAVIMIII 2

VT-mi t d'° /r 0 I • breaths/min I g- ( "-,- f .1 Pr

44 Peak inf pres / PEEP a 'I_

MODE - St on) Alssist), Cf on) C.A.) CV SNI V SV SV S V SV sv RECOVERY 41 ab

M 2 0

41

ta *I

cc 1.-.,

BP/Auto Cuff ET CO2 (ton) Z.S" S Ek1111111ffilliM 0 '3 3 BP/oth F102 (Frac or %) t 8 L . &0 • 81 • 5.c.) lo • g i r Fr I et3

AC ICU Speclly1

OTHER ART line Sp02 (%) ECG

1'-' jr., i LW i.-• -r - 51 - s—

(03 ICJ OA sf c Cr

i 0) 5 Steth- PC/ES

Gas analyzer

CONDITION:

RESP- Sp02- BP

TEMP-sItecOV Liallklall1501111EMILNIIIIIME PIM N-M Block IT/4) litareMIEMI

14

o

. Start ua Room End Z 0 a

Warming 1311(1 1 Pic 1 05/.... Oa:

Cony warmer 0 Ready 0 T. IloS

Begin

tll

End

iVt, Mark will, letters & symbols, EVENTS LI-4 explaiir under REMARKS Position -&-"Pr',-"-- • 6'-‘•-"S /4-V3=4:1C PROCEDURES and CPT Codes: L..t. j

UOCk.g.ti Otic lic"-hal? ClaS 0-ll_ e PrtYci- ill-dr- 4-K 4-ca-"J'S

ANESTHETIC TECHNIQUES: Describe block technique under Remarks

AIRWAY MANAGEMENT: Intubation route, blade, technintet„com&eei(sjo 44„&c,

01.-sfi nIteCt

PATIENT IDENTIFI AT1ON: Typed or written entries: Name, Grade/Rate,

Medical facility

C 1 , 41110 (7) (.(.4_, (

SUR

b 4 t

PROCEDURE LOCATION: "--‘. (--- DATE: I

IC lOCO 6-1 ANESTHETISTS: .._,

MEDCOM - 23562 PAGE 1 OF

q rnpv 1 _ PATICHT•C prrnan IISAPA VI MI

DOD-037140

ACLU-RDI 1681 p.122

a11111 .1-11115 TT V ,11.• a, . l ••..•-,-..........-. _--

MEDICAL RECORDPROGRESS NOTES

(..tital-ID: POD: Admission Date: W jt ,(2)1f (*),,... Diagnosis:6W

t i

Skin assessment must be done initially and every 7 days.

Braden Scale Evaluation See Braden Evaluation Table for Details)

Sensory No impairment Perception Slightly l imited

Very limited 2

Completed I

Mobility No 4 Slightly limited CT,

Very limited 2 Completely immobile I

Moisture Rarely moist 4 Occasionally moist 3

Moist C7 Constantly moist I

Nutrition Excellent 4 Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor ( r)--- I

Activity Walks frequently 4 Walks occasionally 3

Chairfast - 2

Bedfast (4)

Friction and No apparent problem 3

Shear Potential problems (2) Problems 1

Add the total score

Above 20 Low Risk

20 Medium Risk Total Score: 1 .-6 Between 16 and R . Bet ween anc111.__tIlig-i Risk_

Below 10 Very High Risk Note: A Braden Scale Score of less than 15 indicates HIGH RISK-requires immediate Ulcer Prevention program.

Yes_ No_ Location: to A a A Surgical wound (s): • e '. Size: Drainage:

Proc_edUr

Pins: Appearance: P-e.)( -5 ∎ I Tubes:

I Dressing change: 0Y.-bpq -btbrsctn-4,-.-4' 4- Location:

(,D(., Size: Drainage: Cil Pins: Appearance: Tubes:

Dressing change: Yes_ No_ % BSA Partial Full Bum wound (s): Location: Size

Appearance: Dressing change: Location: Size

Appearance: Dressing change:

Pressure Ulcer (s): Yes No Stage 1, II, III, IV (Circle the one that applies and describe below)

Size:_ Location: Dry Granulation tissue Yellow slough Tunneling

Wound character: Pink Moist Odor Purulent discharge Eschar Exudates Undermining

Wet-to-dry Comfeel dressing Carrasyn-V Gel Alginate Type of dressing change:

for wound debridement: Yes No Date/time MD notified Physician notified/consulted CNS notified/consulted for Stage Il and greater: Yes No

Nutrition Referral: Yes No Physical Therapy Referral: Yes No

Action taken: Date & Time


Patient's Identification (For typed or written entries give: Name-last. first, middle: Grade; rank; hospital or medical facility) PROGRESS NOTES

Medical Record STANDARD FORM 509

MEDCOM - 23563

DOD-037141

ACLU-RDI 1681 p.123

PLAN OF CAKe., FO` K DROGKT, IN BREAKDOWN AN PROUD NAGEMENT

P._ . NOTES MEDICAL RECORD Admission Date:

Diagnosis: MEM& IR MEWS*

D. POD:

Date:172MM_____ Time:_ bD,-)-, RN Signature: Skin breakdown as evidenced by immobility, friction, shear, moisture, abrasions, surgical wound, skin tear.

Wound type: Surgical wound (s) Location:_ Drainage: Size:

Diabetic ulcer Tubes: Pins:

Venous stasis ulcer Dressing change: Describe

Other

Burn wound (s): % BSA _ Partial Full

Size Location:

Appearance: Dressing change:

Pressure Ulcer (s): Stage I, II, Ill, IV (Circle the one that applies and describeselow)

Location: ize:

Wound character: Pink Moist DDT Granulation tissue Yellow slough

Tunneling Undermining Odor Purulent discharge Eschar Exudates

Appearance:

Refer to SOP for Dressing Change Instructions.

Please check the appropriate dressing Change:

❑ Wet to Dry Dressing

❑ Carrasyn-V GelDressing

❑ Alginate Dressing

❑ Comfeel Dressing

❑ Pin Site Care

❑ J-Tube Care

❑ Colostomy Care

❑ Chest Tube Care

❑ Burn Care

Select the appropriate products used:

❑ Sterile 4x4 gauze dressing

❑ Sterile 2x2 gauze dressing ❑ Sterile gloves ❑ Kerlix (super sponge) ❑ Gauze bandage ❑ Sterile Normal Saline ❑ Sterile Water ❑ 8 x 4 Sponge gauze ❑ Op-site ❑ Tegaderm clear dressing ❑ Alkare skin prep ❑ Comfeel clear ❑ Comfeel pressure ulcer drsg ❑ Carrasyn-V Gel ❑ Alginate ❑ Bacitracin ❑ Silvadene Cream

NOTE: Document daily wound and dressing change on Progress Note or Nursing Note.

❑ Petrolatum gauze ❑ Hibicleanse ❑ Non-adhesive dressing ❑ Telpha Pad ❑ Carra-smart film ❑ Sterile Q-tip applicator ❑ Xeroform 5 x 9. ❑ Moisture barrier cream ❑ 0.125% Dakins sol ❑ Betadine Swab sticks ❑ 1/2 Hydrogen Peroxide &1/2

Sterile Normal Saline

Select the frequency of dressing change:

❑ b.i.d. ❑ t.i.d ❑ qd

MD Signature and Date:

CNS Signature and Date:

Patient's Identification (For typed or written entries give: Name-last, first, middle: Grade; rank; hospital or medical facility)

Medical Record, SF 509

MEDCOM - 23564

DOD-037142

ACLU-RDI 1681 p.124

NSN 7640-01-18S-7294 518-701

RADIOLOGIC CONSULTATION REQUEST/REPORT (Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)

EXAMINATION(S) REQUESTED AGE SEX WARD/CLINIC

J

SSN (11,

if FILM NO.

REQUESTED BY (Print) cxR

REGISTER NO.

PREGNANT

11 YES n NO

TELEPHONE/PAGE NO.

SIGNATURE OF RE „du)

SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)

/04eniew14--

DATE REQUESTED

DATE OF EXAMINATION (Month, day, year) 'DATE OF REPORT (Month, day, year)

DATE OF TRANSCRIPTION (Month, day, year)

RADIOLOGIC REPORT

PATIENT'S IDENTIFICATION (For typed or written entries glue: Name — last, first, middle, Medical Facility)

JAM

b(61Y-

MEDC ION STANDARD FORM 519-B 4 -83) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.806-8

DOD-037143

ACLU-RDI 1681 p.125

EMERGENCY RELEASE OF BLOOD COMPONENTS SECTION I - REQUISITION ..

❑,R

IPONENTS REQUESTED (Check One)

RED BLOOD CELLS (Crossmatch not performed)

CYTOMEGALOVIRUS

OTHER (Specify)

❑ THE FOLLOWING TESTS HAVE NOT BEEN PERF1RMED:

ALANINE AMINOTRANSFERASE RETROVIRUS TESTS

TEST SYPHILIS SEROLOGY TEST

HEPATITIS TESTS

DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST PRODUCTS FOR TRANSFUSION WITHOUT COMPLETE TESTING. I UNDERSTAND RESPONSIBILITY FOR THE ADMINISTRATION OF THIS TRANSFUSION.

THE IMMEDIATE RELEASE OF THESE BLOOD THE INCREASED RISK TO THE PATIENT AND ACCEPT

PFIY ' __. ---e___ DATE

- - - - TRANSFUSION NUMBER

SECTION II - ISS

RECIPIENT INS ABO/Rh .

A our)

/TRANSFUSION DATA re)

3 v , - s

.

U_(-6.)

INDIVIDUAL A COMPONENTS

ggvd .3 UNIT NUMBER

1ST VERIFIER 2D VERIFIER A ABO/Rh ,

(Signature) (Signature) DATE/TIME STARTED

DATE/TIME COMPLETED

AMOUNT GIVEN REACTION YES/NO

0 11044 0 / 0

0 os U itA5

IDENTIFICATION VERIFICATION The transfusionist (1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate that the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block.

TRANSFUSION REACTION

If reation is SUSPECTED - IMMEDIATELY:

1. Discontnue transfusion, treat shock if present, keep intravenous line open.

2. Notify Physician and Transfusion Service.

3. Follow Transfusion Reaction Procedures.

4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Desclepon

LI URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

❑ OTHER

OTHER DIFFIClikTIES (EQUIPMENT. CLOTS.

IPI< ❑ YES (SPECIFY)

ETC.)

PRE-TRANSFUSION

TEMP: 9 7 S PULSE: I ra B/P: -77_

SIGN VE 6 ( (t)_ e. /11,-

PREP ' 1, (j.t )-- --L,

,(A7N/9--- /1.tr:7--

DATE

r0 --

PATI (NAME- LAST, FIRST: SSN)

,( )—(ji

One copy is placed in the medical records. One copy is return to the blood bank. Red, Purple or Pink top should be drawn and submitted to lab for retroactive crossmatch.

MEDCOM - 23566

DOD-037144

ACLU-RDI 1681 p.126

EMERGENCY RELEASE OF BLOOD COMPONENTS ' • SECTION I - REQUISITION

C MPONENTS REQUESTED (Check One)

RED BLOOD CELLS (Crossmatch not performed)

❑

CYTOMEGALOVIRUS

OTHER (Specify)

❑ THE FOLLOWING TESTS HAVE NOT BEEN PERFrMED:

ALANINE AMINOTRANSFERASE RETROVIRUS TESTS

TEST SYPHILIS SEROLOGY TEST

HEPATITIS TESTS

DUE TO THE CRITICAL CONDITION OF THE BELOW NAMED PATIENT, I REQUEST THE IMMEDIATE RELEASE OF THESE BLOOD PRODUCTS FOR TRANSFUSION WITHOUT COMPLETE TESTING. I UNDERSTAND THE INCREASED RISK TO THE PATIENT AND ACCEPT RESPONSIBILITY FOR THE ADMINISTRATION OF THIS TRANSFUSION.

PHYSICIAN'S SIG

0 (-0-)- 2-

DATE

',-./0 -(1. C

SECTION . II - ISSUE/TRANSFUSION DATA TRANSFUSION NUMBER RECIPIENT

ABO/Rh •

IN D Y Signature) i )_... INDIVIDUAL ACCEPTING COMPONENTS

OU•4

A

I 8 /co v b'l NUMBER ABO/Rh

1ST VERIFIER

(Signature)

2D VERIFIER

(Signature) •UNIT

DATE/TIME DATE/TIME

STARTED COMPLETED

V-1.

Ir •

IiiiLIWMIrgalit 41 -14P1P-4 •

1111 CA agiii•gr,

/0

0

ID /112.-4 &Maga

■ (CL\ 'r° LA

IDENTWICATION VERIFICATION The transfusionisN1st Verifier) must examine the blood bag label, tag and emergency release form to ensure that it matches the patient's name or trauma number on his/her ID bracelet. He/She must sign the emergency release form in the "1st Verifier" block above to indicate that the correct patient identification was made and to document who started the transfusion. The SECOND individual (2d Verifier) must confirm that positive identification of the patient and the blood unit was made by the transfusionist and must sign the form in the "2d Verifier" block.

TRANSFUSION REACTION

If reation is SUSPECTED - IMMEDIATELY:

1. Discontnue transfusion, treat shock if present, keep intravenous line open.

2. Notify Physician and Transfusion Service.

3. Follow Transfusion Reaction Procedures.

4. DO NOT disgard unit. Return Blood Bag, Filter Set and I.V. solution to the Blood Bank. Descnalion

LI URTICARIA ❑ CHILL ❑ FEVER ❑ PAIN

❑ OTHER OTHER DIFFI LTIES

0

(EQUIPMENT. CLOTS.

❑ YES (SPECIFY)

ETC.)

VE Lfte) ,,,z,

94,07A—/- PRE-TRANSFUSION

TEMP: PULSE: 12.5( B/P: 3

SI

P rm i s

—

(":-.. "17...-------

One copy is placed in the copy is return to the blood Pink top should be drawn retroactive crossmatch.

DATh/zO('

medical records. One bank. Red, Purple or and submitted to lab for

E- LAST, FIRST; SSN)

\,-) tck.---(4

MEDCOM - 23567

DOD-037145

ACLU-RDI 1681 p.127


THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT 10ENTIFI TION •

'--\. I

ilii, rep , loec zoo

o 0

/1

DATE OF Op DE ,_, TIME OF ORDER

,i2 AY, _.5 HOURS

LIST TIME ORDER

NOTED AND SIGN

/70/T IC

, /7 (i& /1 7/


PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER '

1 Dee 01 0 /5-00 HOURS

_C) DLit- 0 04 AX 50,p. PA k 7" NOW, V, 0 , DR OW c-r .QTY' ...

....,

NURSING UNIT ROOM NO BED NO.

(X C

t,- t

.2

L Q.-7 n PATIENT IDENTIFICATION

DL6 O`'


V D &c o-7 0 t 30 HOURS

il, 51st 2 kckuse l

• • ,(3C t. f. c:.)

...

,

I liS 1'1 4 III

. _

Ftz---- NURSING UNIT ROOM N9.

A ,..,..,. tab.: tri_ PATIE' per• I ICATLON _A

le.

BED NO.

4. •nr_ • -- t

MEDCOM - 23568

DOD-037146

ACLU-RDI 1681 p.128

PATIENT IDENTIFICATION DATE OF ORDER • \ TIME OF OR R/

HOURS

LIST TIME ORDER

NOTED A D

NURSING UNIT


NURSING UNIT


NURSING UNIT



DA FAOPFIRM79 ■ 2561

MEDCOM - 23569

DOD-037147

REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW .

ko u_S - <_s5

(\circa GL


ACLU-RDI 1681 p.129

DITION OF 1 JUL TT, WHICH MAY BE USED

MEDCOM - 23570


THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.


110 )9( (ssly ig

A DATE OF ORDS TIME OF OR ER

it V . (,

HOURS

LIST TIME ORDER

NOTED AND . SIGN

rove' i IF r Air , u 0 . ailyi i J'/

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DOD-037148

ACLU-RDI 1681 p.130




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MEDCOM - 23571

DOD-037149

ACLU-RDI 1681 p.131

NURSING UNIT D Nom=

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MEDCOM - 23572


PATIENT IDENTIFICATION TIME OF ORD IR DATE OF ORDER LIST TIME ORDER

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DOD-037150

ACLU-RDI 1681 p.132

REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED

MEDCOM - 23573

DA 1FAOPRRM79 4256

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER. IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION OATE OF ORDER 3, TIME OF ORDE LIST TIME ORDER

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DOD-037151

ACLU-RDI 1681 p.133

CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG


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DOD-037152

ACLU-RDI 1681 p.134

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DOD-037153

ACLU-RDI 1681 p.135


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DOD-037154

ACLU-RDI 1681 p.136

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)

For use of this form, see AR 40-407; the proponent agency Is the Office of The Surgeon General.

/VO, ‘k Yr. 2003

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DOD-037155

ACLU-RDI 1681 p.137

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DOD-037156

ACLU-RDI 1681 p.138

CLINICAL RECORD THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION")

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ACLU-RDI 1681 p.139


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For use o this forrn;',see AR 40-407; the proponent anenc • is the Off ice\of The Surgeon General.

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DOD-037159

ACLU-RDI 1681 p.141

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DOD-037160

ACLU-RDI 1681 p.142

CLINICAL RECORD i

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MEDCOM - 23583

DOD-037161

ACLU-RDI 1681 p.143


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DOD-037162

ACLU-RDI 1681 p.144

CLINICAL RECORD HERAPEUTIC DOCUMENTATION CARE P N (MEDICATIONS) '

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DOD-037163

ACLU-RDI 1681 p.145

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDICATIONS) Mo. ‘k 3.

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DOD-037164

ACLU-RDI 1681 p.146

CLINICAL RECORD ,THERAPEUTIC DOCUMENTATION CARE PLA (MEDICATIONS) ,-- For use of this form , see AR 40-407;

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MEDCOM - 23587

DOD-037165

ACLU-RDI 1681 p.147

. Verify by Initialing

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DOD-037166

ACLU-RDI 1681 p.148

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MEDCOM - 23589

DOD-037167

ACLU-RDI 1681 p.149


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It. ,0-1, d■CO „eLc_ ---

)%:. Z

•,.././.

e'-14 i "--Ti 1 i e4ee) r i —•., /et -64' /3...--vA 161-)

17-14 !Iwo :)031111)

04006 FINN

.X.11

a AA,.

It 21.,?!atic_

,19,11.

D

(J 6 St°

2-

?I": -

12.-e. Vn AD -ice' ii pts "1%3° /5-7,e. 11747--A‘Z 4.1',A 1 a .... _i_ tow, 1 ,7g-

6-3 1 ty4

U)

Jim

/v.,/ /71

try p• &I-04,0E /3. / /a4,4, 6,S

.... ..S--- .....L q..., et,

-:--...

U.S. GPO: 1998-454.110/95216

MEDCOM - 23590

DOD-037168

ACLU-RDI 1681 p.150

43/0

b \\

TIME'r

E.

flue PROCEDURE

ET

Intubation

pastric

Tube

D3I 0 Urinary

DPL

Chest

Tube #1

SIZE-

0 Oral ❑ Nasal

Teeth

0 Oral

0 Nasal

eMeatus

7F1CO Supra-Public

O Opened

O Closed

RESULTS,

❑ ETCO2 Change

O BBS Post Int

❑ Post CXR

0 Air ❑ Contents

0 Verified

Suction: Y N

tiReturn cc

0 Herne Dip: + -

LI Secured

O Grossly: + -

Cell count

Sent@

0 Air ❑ Blood

0 Pleuravac cm

0 Autotransfuser

ACCOMPANED BY - RETURN ' -`

-.AMT

AJ5

CT Scan: 0 Contrast

0 Head GYAbd Q1elvis

0 C-Spine 0 T/L Spine 0 Chest

O

A-Gram Site:

L R Chest

Tube #2

12 Lead

O Air ❑ Blood

❑ Pleuravac _cm

O Autotransfuser ,MEDICATION

Vi a A.; R.Ak

DOSE "; . RTE'

032, X51- 3

L R Rhythm: Comments

TIME':

'co

a3:4c$

TIME:. DOSE RTE DOSE RTE

ABG ISITE

1)

Sat HCO3'

1--e+z1.4,1.4-5

03W

6,3

I T✓ TIME

BE pCO

oy 2)

X-RAYS /KO L1,1

TIME a

O D-stick

❑ SHct

hest Initial

o -\ ❑ D-stick ❑ SHct

TBC • GI/C11em ❑ PT/PTT

❑ ETOH ❑ T&S 0 T&C x

❑ Tox Screen

0 Chest Post ET

❑ Chest Post CT

O C-Spine

Pelvis

BLOOD PRODUCTS 'Nir EI

;

O UA

❑ HCG

017 c..•-t

$3-OTHER I I- C._ Le 032C0-1

0 OTHER

CBC:

Chem: MAO AMOUNT" U

AMOUNT

IVF

NGT

Blood

Other

Urine

NGT

EBL

Other

TOTAL

TOTAL

VALUABLES & CLOTHING CiPrin t) A ESRONOE0' TA1

ED Phys None Found

Surgeon Given to Patient

Ane s th

Given to Family

Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696


X-Ray

DISPOSITION RT

0 Home 0

Ortho

Admitted to

Neuro Report Called to

Chaplain Time Transferred

I By

....,retcher ❑ Wheelchair MEDCOM - 23591

DOD-037169

ACLU-RDI 1681 p.151

5 - Localizes Pain

O3? D3

Recta Temp: GCS: TIME RP HR RHY RR SAO2 F110' . MODE ; - E

63D c 72 / 3/ 12-SArS'e 410

JO O

/40

Fa

GLASGOW COMA

EYE OPENiNG VREBLE RESPONSE

Spontaneous (Oriented

4 - Contused

1 - None

T IME

SCALE

MOTOR, RESPONSE •

". beys Commands

PERFORMED BY .:'

0)u

Ilk

616 /1/ /2 /

/ol /oft.,

r AlsA, AISg- AJM 2--

3 To Voice

2 - To Pain 3 • tnapp Words C

2 - Incomp Speech

1 - None

4 - Withdraws to Pain

3 - Flexion to Pain


1 - None

0 Backboard Removed BY:

0 Downgraded BY:

NOTES

/

/

/

MEDCOM - 23592

DOD-037170

ACLU-RDI 1681 p.152

REPORT TITLE OTSG APPROVED (Date)

QI Appr 11 Jun 97 TRAUMA FLOWSHEET The t is Dept of Surgery

tural

AIRWAr:

Patient

TRACHEA! ❑ Midline ❑ Deviated

II CHEST SYMMETRY:

0 PULSE: resent ❑ Absent

BLEEDING: —16

HEART TONES: ❑ Clear ❑ Muffled

a a

RHYTHM: ERegular ❑

PULSES: CTCentral lirKripheral

13 a Absent

13 Crackles


TIME -03

Meds:

Allergies:

Tetanus:

LMP:

x 02 . 1 /min ❑ C-Spine Immob

❑ UKN ❑ None ❑ Yes:

❑ UKN ❑ Yes:

❑ UKN ❑ Current Last Meal/Fluid Intake hrs

TIME:O 0

MED COM: a ©

❑ ETT

❑ Secretions

❑ Labored IdUnlabored ❑ Absent SKIN: Cf Warn ❑ Cool ❑ Hot

❑ Pink CI Pale CI Cyanotic ❑

Qdry ❑ Moist ❑ Diaphoretic

0 CIRCULATION

SECONDARY SURVEY DISABILITY

GCS: E

V

M

SPHIN,OtER TONE:

WNL

❑ None

PUPILS: erqual ❑ Fixed a-F‘ct ❑ Dilated

TM: Er...-1ear ❑ Blood

NECK

C-Spine Tenderness:

Pain @

JVD:

HEART"

LUNGS

BREATH SOUNDS:R-Ettfat rEqual Ci ear

Decreased

—Y11144teezes

HEAD ABDOMEN

Err Soft 0 Rigid err:on-Tender

0 Tender:

0 > = <

0

PELVIS

liKtable ❑ Unstable 0


Herne +l - Prostate: Vb<VNL ❑ Abnl

E

VASCULAR ASSESSMENT

alpable

Dopler

DA 1'aRYM7 8 4 700

REQUI

❑ HISTORY/PHYSICAL



❑ FLOW CHART

❑ OTHER (Specify)

❑ TREATMENT

USE. DIAGRAM TO DOCUMENT INJURIES AND PAIN

(AB)rasion

IAMPlutation

IAV)ulsion

Battle's Signs

(BL)eeding

(B)urn

10)eformity

IE)cchymosis

(Floreign Body

(H)ematoma

(LAC)eration

(P)uncture (W)ound

(Pain)

(S)eatbelt IS)ign

(SItab IW)ound

1-elSi9VY .r-tSTR5rV oun

RN

PREPARED

PH

DEPART LINIC (Continue on reverse)

DATE

/"`1_,.11 vs PATIENTS I pe' or written entries give: Name--last, first. middle; grade; date; hospital or medical facility)

MEDCOM - 23593 D BY DO FORM 2005 EAMC OP 503, 1 Dec 98 I ■.117,3,J1..ETE.

DOD-037171

ACLU-RDI 1681 p.153

PATIENT'S IDENTIFICATION (For typed or written entries give: Name —last, first, middle; grade; date; hospital or medical facility) NAME: RANK: AGE:

UNIT: GENDER:

STATUS: US: AD / CIV IRAQI: CIV / EPW

❑ HISTORY/PHYSICAL

• OTHER EXAMINATION OR EVALUATION


[1] TREATMENT

❑ FLOW CHART

❑ OTHER IS-Pacify)


REPORT TITLE INTENSIVE CARE NURSING FLOW SHEET ..,

OTSG APPROVED (Dare)

QA Appr 8 Mar 89

SHIFT ASS T k, TIME: I INITIALS TIME: INITIALS:

Z PUPILS

4,..

SENSORIUM 9 LI „

id rvui ,rjox 41) C NA I ) '1,Jh

EXTRiF,MITY MOVEMENT SEDATION PAIN CONTROL

ek 1 (0

I X

(f)

RESPIRATORY PATTERN BREATH SOUNDS "-

SECRETIONS 4-077 n c/i.,.hto ("i.z,,G...) --zt/Z•ei 02 SOURCE/FLOW/SA02 VENTILATOR SETTINGS •

>

CARDIAC RHYTHM k-r-E_ 1a3 CAPILLARY REFILL + --35-ec..- ,t_e_ ( -"- PULSES "t) !lb._ i J)_30-a EDEMA -r : ) '

I C., ABDOMEN it- CLISIVIC-te al BOWEL SOUNDS

igl 1-1-1-090 0 q.1(Te 15F-7/-

BOWEL MOVEMENT I $iLtif -e t/1"- riLLI-kic ti-ty-i NGT'OGT TUBE FEDDINGS DRAINS

VOIDING qr. '1--e) 131 COLOR/CLARITY pal- frettIO

i 91/n14-11 A ek

I ci) COLOR INTEGRITY -4-1/0C t i / L

SaykS1

ut.1 rf)

#1 TYPE/LOCATION/SIZE (017671,„; -._

DRESSING CONDITION /7 ?-. V--121; 441-,Y1-- IV FLUID/RATE 1 0 c d6 44c-pirez. 0 aseel/fA

.42 TYPE/LOCATION/SIZE DRESSING CONDITION IV FLIMS/RATE (Continue on reverse)

PlitfrAlii:D BY !Signature & Title) DEPARTMENT/SERVICE/CLINIC

ICU #1, 28TH Combat Support Hospital

I DATE

DA FORM 4700, MAY 73

MEDCOM - 23594

USAPPC V2.00

DOD-037172

ACLU-RDI 1681 p.154

;re 11IIOW . 12 II II 111

11 111

1111 oc4

Irl ISI ISI I I

I I E s Ill

Ell■I II NV' INN

111■I 1111 CNN EMI

MI 1 E c7. IBM

1 I III 2 1N11

I I Ill ,c) I II

I I II ,c° 111 " ri■ gnaw* -6z. , UN

11 . 1 I ,-r` Ell

I I li ,c-0 Ill

MI I II 1E1

IF MI1 _,1 IRA

MISIBEIM ,_c#) Mil MISMEEIN ) V 6' ROI MIMI 1 1 ;:v-, 11571 1 ?-1113111EIM 1

cDtrs v_rz, 1-c212 EllisIM c-‘ Lau

III - Qco\r,) OEM .24... -1111- Icr:,t6_31t? 0 IEC,

IN lc-cg 1 loll

O

CNI O

C■

O O

O

Cf)

co

0

. Cl3 z

1.72. (13

CL

ACLU-RDI 1681 p.155

Pacu Intake Site By

SL dAv- LV -r V (Lt._

Infused Qo

Amount Solution Time

1-310

ADM 30' D/C

1Lan1nUO MIEVOISL9

T, C, & DB.. Incentive Spirometer, Comfort Measures Safety: SR up X 2, Falls Precautions. Privacy Maintained

PR Title)

i •

DATE

it (01 (..K DEPARTMENTISERVICEICLINIC

A

X-rays:

Criteria Activity

(2) Moves 4 Extremities Moves 2 Extremities


Airway

(2) Cough. Deep breath -

(1) Dyspnea. limited breathing

(0) Apnea

Blood Pressure (2) SBP =1- 20 of Pre-op

(1) SBP =1- 20-50 of Pre-op

(0) SBP =1- 50 of Pre-op

Consciousness (2) Fully Awake, audible

crying (1) Arousable to verbal or pain

Color

(2) Baseline color & appearance

(1) pale. mottled. jaundiced

(0) Cyanotic

Circulation (Peds < 5 Years)

(2) radial Pulse Palpable (1) Axiliary palpable. not radial (0) Carotid only reliable pulse

TOTALS: Must be 9 or

greater to WC. otherwise needs anesthesia approval for

0/C.

Patien teaching done: Wound Care, Pain Management, Time

L ra 1 j 1 /s- IC Is )1.11 I

/r1 RR

T

Time

220

240

200

180

160

140

120

100

80

60

40

20

Labs:


Pain (0-10) LOS

Codes

AIRWAY A =Ambu BB = Blow-by M- Mask FT = Face Tent RA = RoomAir NC =Nasal Cannula

V'S X =A-line BF' -

=Cuff BP = Pulse

TEMP S = Skin 0 =Oral A= Axillary T = Tympanic R = Rectal

LOS C =Cervical T= Thoracic L = Lumbar S= Sacral

2_

For typed or written entries give:

ate; hospital or medical faatyl P first,

Name - last,

MEDICAL RECORD•SUPPLEMENTAL MEDICAL DATA For use of this form. see AR 4065; the proponent agency is the Office of The Surgeon General.

OTSG APPROVED Waal

REPORT TITLE

Post-Anesthesia Care Unit (PACU) Flow Sheet

Date: I / z 7 / b 3 Anesthesia Type (Circle)): General Spinal Epidural

Time In: I .{ t IV Sedationrve Block

Allergies: OR Intake: Crystalloid (S-\- --"o Colloid

Pre-op V/S: I )..-t,,, Lk"- LA 1-- OR Output: UOP EBL pr

Procedures: T-4 19 Li- atjT-4 Meds/Times: 1%-lifu-r■ A fj'IL,. ( t"•. r4c....1 . to nn 4,31,..co

(j....-.-,-../._,3 ,i ,2.,kii-oc..ics a 14' GS ,....3 -rt, riietickyts ,.,-DY 2"--1 -Tv,k..t. u •

Pre Op Meds Histor

Drains Hemovac

NG JP

T-tube Foley

TLS

Air2.va Nasal Oral ETT

Trach

Other

0 FLOW CHART

❑ OTHER tro=do

❑ HISTORYIPHYSICAL

❑ OTHER EXAMINATION

OR EVALUATION


❑ TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 23596

Previous edition is obsolete USAPPC 112.00

DOD-037174

ACLU-RDI 1681 p.156

DOD-037175


I/E By Medication & nrr acv.

Time Pain 1-in

Route


Of Motion

Sensory P .

Cap Refill

T Color

Adm ".8) t: 4; Q■ (1) P B 0 {lc-

15' -711,,eht, w 1:: 25' P a ek--- 30'

45'

60'

90'

D/C

Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P = Palpable, D = Doppler, A = Absent Color: C = Cyanotic,

Capillary Refill: B= Brisk, S= S uggish P= Pale, Pk = Pink

C-SECTIONS Adm 15' 30' 45' 60' 90' D/C

Fund. Height ''-----

Lochia ..........._____________

Peripad# --........_____s___

Fund. Cond. ----.....„ -.,_

NURSING NOTES

Pain 1-10

PACU OUTPUT

Time Source • Color/Appearance Amount

Sa02: 9V"6

Discharge Criteria: Date:10 1-a Time:, 4/3 1' PARS: BP: i .sae, HR:j2.3 RR: / Pain Level at D/C 10-101: Intake: Output: Additional Data:

CARDIAC RHYTHM

Time Rhythm Symptomatic? Rhythm Strip Run? / 3/ s S 1..

1 114.—e-j -5,J r

• •-- --• WAMC OP 173-E

Transferred To: c-4-1

Report Given To: Transferred Vi Transferred B Cleared IAW Re

23597 e Signature:

DRESSINGS


Adm 1 z. , - eg>4 41,66-s• ,w- -4- R- c?. 4Tt —) 30' ,s lc 7-i.i.Kie3 p ,._ (...; 4- /c......41-Z-1-. iii.,:: C.---

60'

DIC

/ 2

0 4eXar-it-

b U6-1 p\-\\

ACLU-RDI 1681 p.157

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this Ione, see AR 4066: the proponent agency a the Office of The Surgeon Omni-

REPORT TITLE Post-Anesthesia Care Unit (PACU) Flow Sheet OTSG APPROVED Wale

Date: I it (r-,, 0-- Anesthesia Type (Circle)): a pinal Epidural Drains Airway •

Time In: IV • .. .n Nerve Block Hemovac NG J r

• , - 1W

TLS

■rinlilll. • &b . OR Intake: Crystalloid Colloid Allergies: 1 - ' " Oral

ETT Trach

Other

Pre-op VIS: 3 1lb OR Output: UOP 0 E

Proced res: Mal■Wiggi -b Meds/Times: Ivl.i..)1 , t ll- t.-r-W 1

► .) i , 1 , - u 1

Pre Op Meds History,

Time 'f,n _ •,_._ — gl # _ Pacu Intake

Sa02

ni ba2,-..3-- Tim • Solution

41LIIIIINIMMIIIMMORIMIMIINET Amount Site - By Infused

Fi02 _.i.c, _ :;=,

._... um.

Methods Z -- .-.•&=.1.c...)

240 - .

220 X-rays: . Labs:

• Post-Anesthesia Recovery score

200 Criteria ADM 30' DIC Codes Activity (2) Moves 4 Extremities (1) Moves 2 Extremities (0) Moves 0 Extremities b 2 ..)

7

AIRWAY A =Ambu BB = Blow-by M - Mask

180

160 Airway (2) Cough, Deep breath (1) Dyspnea, limited breathing (0) Apnea

(,

N

/

Z__ FT = Face Tent RA = RoomAir NC = Nasal

V

140 1

\../ \-, Blood Pressure (2) SBP 4- 20 of Pre-op (1) SBP =/- 20-50 of Pre-op (0) SBP =/- 50 of Pre-op

'

2--

Cannula

V/S X =A-line BP

120 pritt

•

100 Consciousness (2) Fully Awake, audible Ming (1) Arousable to veinal or pain I ( I

' == CpuuflfseBP

TEMP

i,

80

A A N Color (z) Baseline cotor & appearance (1) pale, mottled, jaundiced, (0) Cyanotic L Z. 2,

S =Skin 0 =Oral

A = Axillary T = Tympanic

60 r■


R = Rectal

• LOS C = Cervical 20

TOTALS: Must be 9 or greater to D/C. otherwise needs anesthesia approval for WC.

-:,

T = Thoracic L =Lumbar S = Sacral

RR --1- taz tr ..)

v4 0... C T -

.. Time Patien teaching done: Wound Care. Pain Management,

Pain (0-10) T, C, & DB.. incentive Spirometer, Comfort Measures

LOS Safety: SR up X 2, Falls Precautions. Privacy Maintained tcontinue on leVefiel

PRE

q6t,)-'

lien mules give: Name - las: 11/11U

OEPArr TiSIERVICEICLINIC DATE (

i i A4 lt(()

list, midd e; grade; date; hospital or medical lactEtyl

— L.

• HISTORYIPHYSICAL U FLOW CHART

• OTHER EXAMINATION • OTHER axed,' OR EVALUATION

4 • DIAGNOSTIC STUDIES

0 TREATMENT

DA FORM 4700. MAY 78 WAMC OP .173-E, (Revised) 1 Apr 01 (MCXC-DN)

MEDCOM - 23598

Previous edition is obsolete USAPPC V2.00

DOD-037176

ACLU-RDI 1681 p.158

DOD-037177

Time Source Color/Appearance


Of Motion

Sensory P '

Cap Refill

T Color

Q(' ',...- Ju

Adm t'' LI l-ipx.: -- --t (1) N 15' 4 . . . iy,N.- .1.. .._ "a, _I VL 30'

45'

60'

90'

D/C \l/ y Movement/S nsation: + =prese ,-=abs t Temp:C= ool, W = Warm Pulses: P= Palpable, D = Doppler, A = Absent Color: C = Cyanotic,

Capillary Refill: B = Brisk, S=S uggish P= Pale, Pk = Pink

C-SECTIONS r- ' Adm 15' 30' ,45. fi0' 90' D/C

Fund. Height

Lochia

Peripac

Fund. Cond.

DRESSINGS Time Location Type Drainage

Adm L k. . .)<- . 30' MEM IneWrirall PBMI _ — 60' D/C

larill..

NURSING NOTES

k-leb h P r.(fik (...A_Llyo

LaLipt,`.&QD I . 1lf Hart- , d,/t-Pco&n MW-) /r tidilti&FD

( V L6sz 06

Wm/

CARDIAC RHYTHM

Time Rhythm ;V Syroplornatio? Rhythm Strip Run?

BLID 1/4s1,-1-

i_-(----)- (-1:-----)

- --- - - - WAMC OP 173-E

Date: 11 VI Time: (<-1-1 - PARS:' BP: 1%1% T: 011 HR:ITZ--RR:7C Sa02: Pain Level at D/CA0-10): Intake: . •(7: -" Output: Additional Data: Transferred To: 1 C 1,0 I Report Given To: Transferred Via: Transferred By: Cleared IAW Recove

""•--,e Signature - 23599


Medication r)nsaae

Route in 1-10

I/E By Time Pain 1-10

PACU OUTPUT

ACLU-RDI 1681 p.159

NATIONALITY NAT iONALITE

M OM

I PsYcH PSYCH NRI F INC

FORCE / ELEm

A.T A

13C% BC

3. INJURY.' 0LESSURE

FRONT; DEVANT

DIS ASEI MALADIE

AIRWAY TRACI-If(

BACK ARNERE NEAD/TETE

2. UNIT/Lima/

SSN/ MERO

NA FIRST ME/ NOM ET RANK /GRADE

Arifria4101111 FEMALE /FEMME

RELIGION / RELIGION

MALE/ HOMME

WOUND / BLESSURE

NECK/BACK INJURY :

BLESSURE AU COU/AU DOS

BURN , BROLuRE

AM pu TA Non AMPUTATION

STRESS/ TENSION

OTHER apcory.1 , AUTRE (S0e0lied

CONSCIOUSNESS NIVEAU DE CONSCIENCE

TIME / NE URE E. TOURNIQUET, GARROT TIMNEuRE n NO / NON n y ES /OLR

7. MORPHINE, MORPHINE ri NO/NON r---1 DOSE/ DOSE 1 TIME /NEURE IL IV nmE / NE URE yES / out

S. PULSE POULS

PAIN RESPONSE / REPONSE A LA DOuLEUR

UNRESPONSIVE /SANS BEPONSE

ALERT ALERTE

VERBAL RESPONSE, REPONSE vERBALE

7

10. DISPOSITION/ DISPOSITION RETURNED TO DUTY /RETOUR A L'UNITE

f'411',"EVATT ,O7s1RAVATalss',ÀRE:ggem42OUZ4frittclul I ■orgiTt?r"

TIME/ NE URE

Ti. PROVIDER, UNIT/ DEEMER

DD Form 13E0, formmo/«. DEC 91 or 00 Ft:WM 1300 and E■0 Fonn_L 13E10 fTES17. rrhkh ore obsok Ts.

S. FIELD M LE DE L'AVAN ET

MEDCOM - 23600

ACUATED EVACUE

r • -... i,

IL: I I

/2(-7/ //z / -zo

3 zo/ c izo ca/

LO

ACLU-RDI 1681 p.160

36 35

2. .11 F LOCATION ADMISSION AND CODING INFORMATION . REPORTING MTF

8 (State or Country

Code.)

6 4 3 2 1 For use of this form, see AR 40-400; the proponent agency is OTSG

A 117, (QA - . SEX . PAY GRADE • NAME (Last, First, Middle Initial) REGISTER NUMBER

17 14 15 10 11 12 13 9

9. ETHNIC RELIGION

31 BACK- GROUND

E. RACE . AGE AT ADMISSION 6.

19

CI 0

30 29 26 27 28 23 24 25 22 21 20

1 0 12. SOCIAL SECURITY NUMBER 11. FMP ETS 10. LENGTH OF SERVICE

32 33 I 34 44 39 40 41 42 43 45 37 38

C) O C) 0

BRANCH/CORPS HOUR OF ADMISSION

13. MARITAL STATUS ORGANIZATION (Active Duty Only)

46

16. DP CODE OF RESIDENCE 15. BENEFICIARY CATEGORY 14. FLYING STATUS

47 48 49 I 56 57 58 59 61 54 55 60 53 52 51 50

8' 7 K PREV ADMISSION 19. TRAUMA MOS i7. UNIT LOCATION (State or

Country Code) 62 63

YEAR 71 70 67 68 69 66 64 65 NO

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE WARD 20. SOURCE OF ADMISSION/ AUTHORITY FOR 1 ADMISSION

72 ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

23. DATE OF DISPOSMON (YYYYMMDD) 22. MTF TRANSFERRED TO 21. TYPE OF DISPOSITION

81 82

2 0

83 84 85

0

87 86 88 80 75 76 77 79 79 74 . 73

-Z.

26. DATE THIS ADMISSION (Y YYYMMD D) 25, MTF TRANSFERRED FROM 24, CLINIC SVC - ADMITTING

102 J 103 f 104 I 105 106 97 100 101 95 . 99 96 98 93 92 91 90 89

3 I R" .2 0 0

29. DATE INITIAL ADMISSION (YYYYMMDD) 28. MTF OF INITIAL ADMISSION 27. LOCATION QF OCCURRENCE (Battle Casualty Only) 107 1...__ 115 116 117 118 119 120 • 122 121 111 112 114 113 108

S GSci (2) ZS-

FOR LOCAL USE

,&• q (i) 2--

re.-0 , Th

Li- SO

SIGNATURE 0 DMITING CLERK ADMITTING OFFICER (Signature, as required)

OA FORM 2985, MAR 2000 EDITION OF MAR 89 IS OBSOLETE UWAVLW

MEDCOM - 23601

DOD-037179

ACLU-RDI 1681 p.161

Signature, as required)

C2"

inmaled Facsimile - DA FORM 2985, MAR 20(

1/ 1. Reporting MTFN:7:1-- 2 MTF L.,cation

1111.11111.

IZ

3. Register Number Name (Last, First, MI) 4. Pay Grade

MIE 6(..9-)

FGN

5. Sex

M

Admission and Coding Information For use of this form, see AR 40-400: the proponent agency is OTSG

6. DoB (YYYYMMDD)

1971-01-01

10. Length of Service

1 7. Age at Admission 8. Race 9. Ethnicity Religion

32Y X 9

ETS 11. FMP 12. Social Security Number

MEM 99

Organization (Active Duty Only) 13. Marital Status Hour of Admission Branch / Corps:

03:00

14. Flying Status

17. Unit Location


Direct from ER


TRF-OTH


ABA - GENERAL SURGERY

27. Location of Occurrence

IZ

15. Beneficiary Category 16. Zip Code of Residence:


18. MOS

19. Trauma Prey. Admission

BC NO

Ward: Name / Relationship of Emergency Addressee

I CW 1 Address of Emergency Addressee

Telephone Number of Emergency Addressee


2003-12-17


2003-11-08

28. MTF of Initial Admission 29. Date of Initial Admission

2003-11-08

Name and Location of Medical Treatment Facility:

3

FOR LOCAL USE


Admission Diagnosis Narrative: GSW L BUTTOCKS AND THIGHS



Signature of Admittin C

MEDCOM 23602 rD

DOD-037180

ACLU-RDI 1681 p.162

'Automated Facsimile

....PATIENT TREATMENT RECOk ,;OVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

's Name

1-, (6,

5. Age

27Y 6. Race

X Religion 8. LnthOfSvc

12. SSN /13. Organization

3. Grade

FGN

10. PrevAdm

NO

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ICW1

4. Sex

M

11. FMP

20

9. ETS

Admission Remarks

15. FlyStatus 17. Dept / Ben

K78-PRISONER OF WAR/INTER 20. Type Casei

DIS

18. BranchCorps 19. UIC /ZIP


Direct from ER

24. Name/Relation of Emergency Addressee

27a. Address of Emergency Addressee

29. Re ortingMTF

-

26. Date of Disp

2003-11 ;0r LJ 28. Date This Adm:

2003-11-;,1

30. Date Init;ly

2003-11- 1

AdmittingOfficer.

111111W6( - t_

32. Units Blood Components

22. Hour Of Adm:

10:35 23. Clinic Service

ABD - NEUROSURGERY

25. Type Disp TRF-OTH

27b. Telephone No


Marital Status:

In/Out Patient: Inpatient DoB: 1976-08-19

MOS:


ConLv / Coop Care Days Supplemental Care

Signature of

Automated Facsimile - DA FORM 3647, May 79 MEDCOM - 23603

Absent Sick Days Other Days Bed Days Total Sick Days

C)4

icer


L FACAIL HEMOTOMA, L SHOULD SHRAPNEL,R HIP SHRAPNEL

35. Total Days This Facility Absent Sick Days i Other Days


ConLv / Coop Care Days 1 Supplemental Care 1 Bed Days Total Sick Days

DOD-037181

ACLU-RDI 1681 p.163

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ABBREVIATED MEDICAL RECORD Standard For= 839

GENERAL SERvICES ACMINISTRAr.CN AND !•TERAGENCY COm?.iiTTEE. ON ME.7.1iCAL RECORDS P4r1..IR 4: CFR) 201-15.505 CCTCEER 1975 539-156

MEDICAL RECORD, • ABBREVIATED MEDICAL RECORD

PERTINENT HISTORY. CHIEF C MPLAINT. AND CONDITION ON ADMISSION (Eol g r doff of off ofwion

PRoGRES f Enter date of di:charge a nd /Inca diagram.)

MI? LA_Thc

ov)5

l iT MEDCOM -23604

DOD-037182

ACLU-RDI 1681 p.164

DATE NOTES

LAST NAME MIDDLE INITIAL ID NUMBER FIRST NAME

/4/6-3t-I old .

Of- _AAILL.A LA Pt CIO pain 40 phip, itednoz6 0(141 rnD oam qpnithmo-

aciz-,61

MEDCOM - 23605 \ID ((t t

tit06 5/1999) BACK

USAPA vi.00

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DOD-037183

ACLU-RDI 1681 p.165

MEDICAL RECORD ...., . 1 r.,....,.... . - .n a.v.,,u_ ncr-nuuuu I luri

PROGRESS NOTES

DATE NOTES

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MEDCOM - 23606


STANDARD FORM 509 (REV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 1 01-11.203(b)(1 0)

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DOD-037184

ACLU-RDI 1681 p.166

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AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD

DATE NOTES



DEPART./SERVICE

LAST

I HOSPITAL OR MEDICAL FACILITY I RECORDS MAINTAINED AT

SPONSOR'S NAME I SPONSOR'S ID NUABER I FIRST


MI ISSN or Other)

141111111!11144 MEDCOM - 23607


STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10)

USAPA V1.00

DOD-037185

ACLU-RDI 1681 p.167

LAST NAME FIRST NAME MIDDLE INITIAL !D NUMBER

DATE NOTES

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MEDCOM - 23608

TANDARD FORM 509 (REV. 5/19 9) BAC

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DOD-037186

ACLU-RDI 1681 p.168

MIDDLE INITIAL ID NUMBER

LAST NAME I FIRST NAME

NOTES

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MEDCOM - 23609

DOD-037187

ACLU-RDI 1681 p.169

DOD-037188

t DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY

AUTHORIZED FOR LOCAL REPRODUCT10

PROGRESS NOTES

DATE NOTES k (ce. L

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STANDARD FORM 509 (REV. 5/1999 Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(1 0

USAPA V1.0C

MEDCOM - 23610

• RELATIONSHIP TO SPONSOR

LAST SPONSOR NAME

FIRST

ACLU-RDI 1681 p.170


DATE NOTES

R KkAt - 03 6RTT-0 GotNYSuur

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MEDCOM - 23611 TANDARD FORM 509 (REV. 5/19 91 BAC

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DOD-037189

ACLU-RDI 1681 p.171

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PATIENT'S IDENTIFICATION; /for typed Of fatten exam Pile Name las4first Diddle • ID NoarSJI4Ser,OtteofBc fianklfiradej REGISTER NO.

WARD NO.


STANDARD FORM 509 mEv. snow Prescrillad by csAnon FPMR CFR) 101.11203112/110)

USAPA VISO

MEDCOM - 23612

'MEDICAL RECORD PROGRESS NOTES AIITHO

DATE NOTES

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DOD-037190

ACLU-RDI 1681 p.172

C. fVe.rr Evvvz V\t. e-e_An

MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION

CHRONOLOGICAL RECORD OF MEDICAL CARE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) DATE

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CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record

STANDARD FORM 600 (REV. 6-97) Prescribed by GSNICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2.00

MEDCOM - 23613

■sittrus

SSNIID NO. RELATIONSHIP TO SPONSOR

DEPART.ISERVICX_) k.sLt-5)-

1 RECORDS MAINTAINED AT

ifor typed or written entries, give: Name - last lust, middle; ID No or SS1V; Sex; Date of Birth; Rank/6lat/0 I REGISTER NO.

DOD-037191

ACLU-RDI 1681 p.173

DATE

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)

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MEDCOM - 23614

USAPA V2.00

DOD-037192

ACLU-RDI 1681 p.174

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT

(Patient)

LOG NUMBER TR

RECORDS MAINT ED AT

PATIENTS HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS

DATE Day, MOTnth, Year TIME tio 70

CITY STATE ZIP CODE TRANSPORTATION TO FACILITY

"- SEX

pl\ DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE

AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO PRP ADDITIONAL INSURANCE

AGE

....0 HOME PHONE FLYING STATUS DD 2568 IN CHART

AREA CODE NUMBER MEDICAL HISTORY OBTA.rED FROM NAME OF INSURANCE COMPANY

;CENT MEDIC TI 1 _k

, ( INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT

ITEM YES NO WHEN (Date) DATE LAST VISIT 24 HOUR RETURN n YES INO

IS THIS AN INJURY? WHERE TETANUS ALLERGIES

(\'

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INJURY/SAFETY FORMS DATE LAST SHOT

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COMPLETED INTITIAL SERB YES • NO

a

HOW

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rue k VITAL SIGNS

i. 4.-c1- N ^

CATEGORY OF TREAiiMENT

TIME

BP

PULSE

RESP

TEMP

WT

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URGENT

❑ NON-URGENT

TIME

k0 INITIALS

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19

C-SPINE

LS SPINE

HEAD CT ANKLE R/L

ORDERS ,MONITOR

ORDERS OMPLETED BY /40 11

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TIME n ECG

PATIENTS RESPONSE

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(o •

DISPOSITION

n HOME n FULL DUTY MODIFIED DUTY UNTIL

DISPOSITION QUARTERS /OFF DUTY n 24 HRS. n 48 HRS. n 78 HRS. RETURN TO DUTY

PATIENT/DISCHARGE' INSTRUCTIONS

CONDITION UPON RELEASE

IMPROVED ❑

UNCHANGED

❑ DETERIORATE

ADMIT TO UNIT/SERVICE

TIME OF RELEASE

REFERRED ON.

I have received and understand these instructions

TO WHEN

9

PATIENT'S SIGNATURE

EMERGENCY CARE AND TREATMENT (Patient) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSMCMR FPMR (41 CFR) 101-11.203(bX10) USAPA V1.00

PATIE TS IDENTIFICATION (For typed or written entries, give: Name — last first, middle; ID no. (SSN or other); hospital or medical • '

Ica

MEDCOM - 23615

DOD-037193

ACLU-RDI 1681 p.175

ABG/PULSE OX BC

YE C- RADIOLOGY Check if read by radiologist

10.6/ — -- n H/H

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'. 3 RESULTS P02 PH

C7- PCO2

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APTT MICRO GLU ETOH BHCG

kkk

CONSULT WI

DIAGNOSI

PATIENT'S IDENTIFICATIO

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PROVIDER SIGNATURE

11.1 0 0

NSN 7540-01-075-3786

MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor)

TIME SEEN BY PROVIDER

TEST RESULTS

PROVIDER HISTORY/PHYSICAL

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ACTION

EMERGENCY CARE AND TREATMENT (Doctor) Medical Record

STANDARD FORM 558 (REV. 9-96) Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(bX10) USAPA V1.00

MEDCOM - 23616

DOD-037194

ACLU-RDI 1681 p.176

Pressure Ulcer (s): Yes Stage Ill, [V (Circle the one that applies and describe below)

rgical 1.vound (s): es No L.ocation Tubes: Dressing change:

°utter zed 2-CM COC(Drainage: rrIn • bloody. Appearance: VA" - • ram

01,101 GLIF5 ► \

• • _._.. –, •,•.. —J....30,1w i MEDICAL RECORD , PROGRESS NOTES

Admission Date: //`77-03 Diagnosis: ...)

-7;2-7.4,/ ,_,./..,..,,-...-+-, •e. L a eiez/ /-c- - - /1-:HD: POD:

Braden Scale Evaluation (See Braden Evaluation Table for Details )

Mobility No limitations Slightly limited Very limited Completely immobile

Sensory No impairment a Perception Slightly limited 3 Very limited 2 Completed t

Moisture Rarely moist Occasionally moist Moist 2 Constantly moist I

Nutrition Excellent 4 Adequate (Eats >50%) 3' Adequate (Rarely eats) 2 KIP01 Very poor 1 3dows)

Friction and No apparent problem 411* Activity Walks frequently 0 Walks occasionally _, Chairfast ., Bedfast

Shear Potential problems Problems 1

Add the total score

Above 20 Low Risk Between 16 and 20 Medium Risk Between 11 and 15 High Risk Below 10 Very High Risk

Note: A Braden Scale Score of less than or equal

Total Score

to 15 indicates HIGH RISK -Requires immediate Ulcer prevention irct, r-r1 nne 1 .\ program.

Size: Wound character: Pint Moist Dry Granulation tissue Odor Purulent discharge Eschar Exudates

Location:

Yellow slough

Type of dressing change: Wet-to-dry Comfeel dressing

Physician notified/consulted for wound debridement: Yes CNS notified consulted for Stage I1 and greater: Yes No Nutrition Referral: Yes No Physical Therapy Referral: Yes No Action Taken: Date & Time:

Carrasyn V-Gel Alginate

No

REGISTER NO. i WARD NO.

Patient's Identification (For typed or written entries give: Name-last. first, middle:

Grade: rank: hospital or medical facilithy) PROGRESS NOTES

Medical Record STANDARD FORM 509

AIM MEDCOM - 23617

DOD-037195

ACLU-RDI 1681 p.177

. 511-419

M

POST-

MONT H•YEAR

19 HOUR

PULSE TEMP. F (0) (S)

105°

180 104°

170 103°

160 102°

150 101°

140 100°

130 99° 98.6°

120 98°

110 97°

100 96°

90 95°

80

70

HOSPITAL DAY

DAY

111112MIMMIMITUr

1111111111 0

aitargumn 1,11 11111

NSN 7540-00-634-4124

.. •

........

TEMP. C

40.6°

40.0°

39.4° 0

38.9°

a)

38.3 ° cc

37.8°

37.2°

37.0° 0-

36.7 °

36.1 ° a) 0

35.6°

35.0°

EDICAL RECORD VITAL SIGNS RECORD

........ • -

.... • . • • • •

........ • •

60

50 • ...........

40 ...

RESPIRATION RECORD

0

0

BLOOD PRESSURE

HEIGHT: WEIGHT

/17

122i-p-f

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PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; ID No. (SSN or other); hospital or medical facility)

(


VITAL SIGNS RECORDS

Medical Record

STANDARD FORM 511. (REV. 7-95) Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-1

MEDCOM - 23618

DOD-037196

ACLU-RDI 1681 p.178

RAPIDPOINT CiAGANALicm V4,54 SERIAL #005485 '11/08/03 10:44

Patient ID:11,1111 \:,(C;.) -" Test Name : T Test Result:= 14.0 sec. Ratio = 1.1 Calculated INR = 1.25 Sample Type:citrated wh. blood Test Date :11/08/03 Test Time :10:42 Card Lot :080201 Operator

RAP DPOINT COAG ANALYZE V4.54 !AL #005485 11/0: 3 10:48

08-11-03 10:36

Patient Limits

WBC 8.5 110"3/uL 4.5 10.5 RBC 4.87 x10"6/u1 4.00 6.00 Hgb 10.6 L g/dL 11.0 18.0 Hct 35.5 X 35.0 60.0 HCV 72.7 L fL 80.0 99.9 MCH 21.7 L pg 27.0 31.0 rete 29.9 L g/dL 33.0 37.0 Plt 294. x10"3/uL 150. 450. LYX 19.2 L X 20.5 51.1 LY# 1.6 xtill/u1 1.2 3.4

/ IC Test . -ult:= 19.8 sec.

***RESULT OUT OF RANGE*** Sample Type:citrated wh. blood Test Date :11/4-wi It,-,A Time 1H11.4d

d 10t -:100 08 erator

up!

/' /

RAPIDPOINT COAG ANALYZER V4.54 c1ER1Ai #005485 11/08/03 10:50'

1 it ID: ame : I

lest suit 15 sec. ***RESU T 118T RANGE CHECKED*** Sample T e:citrated wh. blood Test Dale ;11/08/03 Test lime :1Q:46 Card Lot :10 208 Operator =MIN

U,1-5"/-V!

-- i -STAT EG.S+

09-11-03 06:06

Patient Limits

W 5.8 x10'3/ig •.5 10.5 RRE 4.64 x10'61:IL 4=00 6.00 HIb 10.2 L g/TL 11.0 18.0 Hct 33.9 L 1 35.0 60.0 riCV 73.1 L fL 80.0 79.9

.1E8 22.0 L p9, 27.0 31.0 DC ,. 30.1 L g/dL 33.0 37.0 Flt 26Y. 6r3/iii 150. 450. LY1 34.8 1 20.5 51.1 LA 2.0 x10"3/11L 1.2 3.4-

Pt :111111111 Pt Name:

Na 132 mmol/L

4.3 mmol/L

TCO2 22 mmol/L

Het 37 %PCV

Hb* 13 g/dL

*via Het

at 371:

PCO2 47.0 mmHg

P02 31 mmHg

HCO3 26 mmol/L

E;Eecf 1 mmol/L

502* 55 %

*calculated

Sample Type_:

08NOV03 10:56

Oper: 0

Physician:

Ser# 42011

Ver: JANSO468 CLEW R93

lu. IJSiTT

MEDCOM - 23619

DOD-037197

ACLU-RDI 1681 p.179

r , WayilS . -tion: - ;II 1—R. EQUESTING PBYSICIAN: 1 L: jRATORY RESULT FORM

(--/ / I I (Subject to the Privacy Act of 1974) . A ST.. FIRST, Nil. I DATE Ii VAC 1 SQN/Prs-

._____ .-.. (Herna ,, 4. 1 . ,

• . . . . - • CJOrialysis . ... . . 'Misc. Serology

:1E87' RES , R.L.v. RANGE TEST RESL11,7' L RE.F. RANGE TEST RESULT I REF. RAA . rGE

.--"IBC 4.8- 10.3 x 10' Color ! NIA RPR 'Negative

BC RBC 4.7-6.1 x 10° App ' i

----1 I t Nfi -1 Mono 1_

eolt;ve I - "

Hgb 14-18 aid( (M) 12-16 p/c11(T)

Glu •-..ce..,ailve . . :Microbiology .. . *

Hct 42-52% (M) . 3747%(F)

Bili ' Neo_atiVe i " i

Soarce

MCV 30-94 il (M) . 31-99 fl(F)

Ket I Negative Gram Stain

Pit 1301.500 x 10" verified

SG Ni:' O. cc Bid Negative

Negative Lymph % 20.5-51.1% Bid Negative H. pylori

M icro Parasites

1

. •

.• (Hematogy).MOunlpifferentill pH N/A

Seg Mono Prot I Negative Malaria •

Bands ; --I

Eos Urob I 0.2 - 1.0 0 & P

Lymph i Baso Nit Negative Other

Atyp Imm Leuk Negative • Nflci-oscopic Vrizialysii: •

RBC Morph

HCG • Negative

.

Spun Hematocrit ;

42-52% (M) 37-47% (F)

• . CSF • . . Blood Bank .. . . . . .

Sed Rate Cell Count

MUST SUBMIT SF 518 WITH EVERY UNIT REQUESTED

Other

----

Directigen ; I

Negative ABO/Rh _.

. .

- ' • •••••• CosgubitionStudies, •

• . .

. .. BloOd Raiik. Unit Crossinatch . ..: . • . : :-: • . (MUST,SUSMIT SE 518.WITH . EVERY UNIT OF BLOOD . . •

.•.- REQUESTED) .. . •• - -. . - ... •-.. I - . TEST RESULT 1 REF RANGE UNIT 1 TYPE , CROSSAL4TCH

I-1 PT

Ir 9.8-13.6 secs I

A PIT ; 21-34 sets I

D dimer : n0 tiwird . - --'-

F DP

4 1 <IOug/m l ! I

REMARKS: 1 . J

REPORTED BY: ( DATE: LAB ID NO.:

MEDCOM - 23620

DOD-037198

ACLU-RDI 1681 p.180

REPORTED BY: LAB ID NO.: .

MEDCOM - 23621

DATE:

Ward/Section: r REQUESTING PHYS1Cr

4.8-10.8 x 10'

4.7-6.1 x 10

======= PICCOLO

08/11/03 10:39

REFERENCE OALIE PATIENT min k-( 4A)- METLYTE 8

DISC LOT #: OPER #: 3151AA4 • SERIAL DR #: 000

:

. 0000100494 ..... . .

............

GLU 157* 73-118 MG/DL BUN 7 7-22 MG/DE CRE 1.7* 0.6-1.2 MG/DL CK 163 39-380

U/L 128-145 MMOI/L K4

4.8* 3.3-4.7 MMO//L CL- 100 987108 MMOt/L I 18-33 MMO/iL

INST OC: OK CHEM OC: OK HEM 0 , LIP 1+, ICT 0 Spun

Hematocrit

RBC Morph

Lymph

Lymph % 20.5-51.114 •

130-500 x 1 verified

Negative

0.2-1.0

Negative

Negative

Negative

'N/A

Negative

WA .

Negative

Negative

Negative

Directigen

COagulationtudies.

=OLT

9.8-13.6 secs

21-34 secs

<10 ug/m1

DOD-037199

ACLU-RDI 1681 p.181

Ward/Section: REQUESTING PHYSICIAN: .• - CHEMISTRY RESULT FORM (Subject to thc Privacy Act of 1974)

LAST, FIRST, ML DATE TIME SSN/PSEUDO SSN: •

:‘3...-. .,:0:. . ' iT ....„-,,-.....i,zWg .V..ig:7-/ ..•;.;;';?pi.f.1'.`:-:*.-0-:-.-,:l.;S,,r..-tit,:r.:;:..1.Z:a--37in,:(,:f:la

it'i'W Vkliiaiii llAtT,i,:f: :e:::.1,::-..A,.r...;-:;E:$:':-•.': ,.;74.-:.4.,..lis.s1/4.-'4.7.1:!,‘4,g. :•:"•.....--: .t01.4% ' /6 raii 0;-":='.'- -.'lc.:f.t..-,-, xtA::.-:....-.4i,rii. ,. "..t.5,..*..3'..K:,.. -$1:

TEST RESULT REF. RANGE TEST RESULT REF. RANGE

TEST RESULT REF. RANGE

Na 138-146 mmoUL ALB 3.5-5.5 rid GLU 73-118 mg/dl

K 3.5-4.9 mmol/L: ALP 26-84 on BUN 7-22 Ing/d1

Cl 98-109 mmol/L ALT 10-47 ull Cg+ 8.0-103 mg/dl

PH - 7.31-7.45 AMY 14-97 u/1 CRE 0.6-U Ing/d1

PCO2 35-45 mmHg (art) 41-51 mmHg (vas)

AST 11-38 u/1 NA* 128-145 ramo1/1

P02 111-1435 mmHg (.rt) WA (yen)

TBIL 0.2-1.6 mg/d1. ic.4 . 33-4.7 ramolil

TCO2 23-27 rmnoVL (art) 24 -29 mmol/L (veu)

BUN 7-22 mg/d1 CL . 98-108 mmol/1

HCO3 22-26 roma& 04 23-21 mud& Nen) CA'* 8.0-103medl tCO2 18-33 mm..4/1

s02 95-98• CROL 1D0-200 raga !yr.%"' k6i Iiike " -.-..Milkx,if.. `1:24....,.....k..14'.:

*I- iligg':.7%.:.?

REF. RANGE BEecf (-2)-(+3) • mmol/L

CRE 0.6-1.2 mg/dl TEST RESULT

AnGap 10-20 mmol/L GLU 73-118 mg/d1 ALB 33-5.5 g/d1

Ca 1.12-1.32 mmol/L TP -8.1 g/dl ALP 26-84 till

BUN 8-26 mg/d1 ''''-''... •;;. 7.5..".tip.;."-i

ieiiii:b . ' —dr ...' :-.-: t.,; ir.j.-5-L- ..

ALT 10-47 u/1

GLU 70-105 mg/d1 TEST 41K •" REF. RANGE

AMY 14-97 tit

Creat 0.7-1.5 mg/c11 GLU 73-118 mg/d1 AST 11-38 till

Hct 38-51% PCV BUN 7-22 mg/di TBIL 027 1.6 mg/dl

Hgb 12-17 01 CRE 0.6-1.2 mg/dl GGT 5-65 u/1

F.:W .4iiii- ..;:•;•L'-.1=.11.. •. .;:',' .1:':‘z-7..71..-.:Zfai,...I. :..r.:- ,::‘• -- ":". :.'74:'-:.g, CK 39-380 u/1 (M)

30-190 u/1 (F) TP 6.4-8.1 g/d1

TEST RESULT REE RANGE NA' 128-145 mmo1/1

Troponin-1 IC 3.3=4.7 mmol/1 i TEST `GE

Drug of Abuse

_CI; 98-108 mmol/1 NA"' 128-145 mmol/1

1.0O2 18-33 mmol/1 K4. 3.3-4.7 mmol/1

CL: 98-106 nyro1/1

tCO2 18-33 mnIo1/1

REMARKS:

REPORTED BY: DATE: LAB ID NO.:

MEDCOM - 23622

ACLU-RDI 1681 p.182

I , YES 1 • E:

''•-" N " • ION 7. / OA 7r: OF E.P-3,1- (Hon:A.d.y. y) (716 x

-,•••.:•10LOGr- RT I DA ••.‘ OF TRA.NSCREF-TION (1•1•x■ -•7‘. - --7 . .. _ •

OA- 4e•A'(

peiu- f -t- s ale(

RADIOLOGIC CONSULTATION REQUST7RE-POT

SS•N

11.P.O/CLiNIC

0

1 REC , S7C R. r, .

LVD 6,rovzikid -4\ 11c-k ( i \ --A

• •-•••:"..7c.:*-

F-0 F.1 3-C 5

MEDCOM - 23623

DOD-037201

ACLU-RDI 1681 p.183

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS, IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM 15 USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION LIST TIM

ORDER NOTED ANO

SIGN


-2_

I • ,.. ILt ... .. IIIIIIMPIMIMMILIAlt _ . . III

1 BED NO rg

DATE OF ORDER ^

41

Ell

a (3

40 IN Fr 401 is

1111 DATE OF ORDER TI OF ORDER I

Esimmaraing ,,,,,I,' st, NI

TIME OF ORDER

NURSING UNIT

PATIENT IDENTIFIC • ION

NURSING UNIT


NURSING UNIT

ROOM NO.


HOURS

NURSING UNIT

c740/

ROOM NO.

DA 1 FArRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 23624

HOURS

ROOM NO.

BED NO.


DOD-037202

ACLU-RDI 1681 p.184



41111111 I ROOM NO. B f 0 NO.

NURSING UNIT

PATIENT IDENTIFIC


THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER

12' 1 i ' ON 3 TIME OF ORDER

HOURS

LIST TIME ORDER

NOTED AND SIGN

\NI 0

In1 r AP a • • A 111 a le •

....0 ..'

fry} i(0 --,

) TIME OF ORDER

HOURS

--..


HOURS


HOURS


DA 1 FAOPRRM79 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 23625

DOD-037203

ACLU-RDI 1681 p.185




•

...

DA T77 RDER TIME OF ORDER

ill /P.,,..7 HOURS

LIST TIME ORDER

NOTED AND SIGN

./. .-...,

I URSING UNIT

o---- ROOM NO. 111 .

\ . ATIENT IDENTIFICATION DATE OF ORDER TIME C.:4F4RDER

11 Oar)? 1 HOURS

0

,%,) ,,z _„, WV \ Off111/1/1 e h

,t

Viw qyiltA p• e-?( D- Vvy-coce,i- ' ro (0 ° 1 •

qirrlie NURSING UNIT


ROOM NO. BED N

t.

NURSING 7-

F 0

HOURS


PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

HOURS

NURSING UNIT ROOM NO. BED NO. •

DA IF:4419 4256 REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.

MEDCOM - 23626

DOD-037204

ACLU-RDI 1681 p.186

6((S-7 AAA

DA FORM 4677, 1 OCT 78 USAPA V1.00

CLINICAL RECORD

VERIFY BY INITL4LING Mo. ( Yr. 2003

INITIAL PROPER COLUMN FOLLOWING EACH COMPLETION

THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION ) For use of this form, see AR 40.407;

the proponent agency Is the Office of The Surgeon General. SONDMISPaneSOMOSA

RECURRING ACTION, FREQUENCY, TIME

-111111Nct\wf

MAdsw. \ ∎b T.

---111111Kic-):40e)3(:5"

HR CLERK/ NURSE

ETED

13 PI

St

b.

ORDER DATE

DATE COMPL

Pe)

ALLERGIES: ED YES 5I NO P._ MARY

APs S-r ^tt t"PsPcî_,


AIM -7(0)


D 8 9 10 11 12 13 14 15

E 16 17 18 19 20 21 22 23

N 24 01 02 03 04 05 06 07 MEDCOM - 23627

ADDITIONAL PAGES IN USE: DYES n NO

PAGE NO•

DOD-037205

ACLU-RDI 1681 p.187


THERAPEUTIC DOCUMENTATION CARE PLAN ( NON-MEDICATION) Mo Yr 2003

Order Date

Clerk Nurse SINGLE ACTIONS Date to

be Done Time to be Done Time Done Initials

NOI 'k ii ' . -:-'. \C- .-\A) L--- - P\-C\ I-C3.\ . . (ZY= f VW

CAS

Com. — --allb■ -• ,

((-0 t___..,b,,_ C-P--___ ‘,(- .t-Nr) q5c1 I\LVC4.3

- _

- - - - -fm

— - -

- _

- _

- — — —

Order/

Dan Date Clerk/ Nurse



TIME/DATE COMPLETED - - - — - -

- - — - - - -

- - - - - - INI. ■I

... ... ... ... ... ..

... .... ... ...

USAPA V1.00

MEDCOM - 23628

DOD-037206

ACLU-RDI 1681 p.188

CLINICAL RECO,U THERAPEUTIC DOCUMENTATIO CARE PLA_N (MEDICATIONS) For use of this form, see AR 7;

the proponent agency Is the Off co of The Surgeon General.

.., Mo, 1 Yr.

VERIFY BY

ORDER DATE

INITIALM

CLER / NUR E

, INITIAX, PROPER COLUMN FOLLOWING EACH ADMINISTRATION


HR DATE DISPENSED

C14 ',_ D Niim 4 K . . tft\l' NSD \2_Gcc) 1-1 ('-c\ zt, ‘ 8

.\ \ \ k--- \r\l\rvC t- __if- MI i (ISS alliONCCS : -ter' \\/

Ka i

. = ,

3NOV • \AOXY- 9) VD 91Z) (.0 ??-7

ALL ERGI EY ED YES

MIZP)

PRIMARY DIAGNOS 5^

,-- L--

• Sk1-00t.DE IF— .-k-k.e,i2t.-L>,

' . t P F-Ak-CAPNEL,

ADDITIONAL

0 r ES

PAGE NO

El PAGES

NO

IN USEt

PATIENT IDENTIFICATION,

DISPENSING TIMES


D 7 8 9 10 11 12 13 14 -f (62S 14 E 15 16 17 18 19 20 21 22

N 23 24 01 02 03 04 05 06 Pak a cnom • ^Rim

1 FEB9 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.

MEDCOM - 23629

DOD-037207 ACLU-RDI 1681 p.189


THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS) Mo. c ( Yrq

Of Date

Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to

be Given be Time to

Given Time Given Initials

I

(C-L --- 2— kcli\\

Order/ Expir Date

Clerk/ N urse


INITIAL . PROPER COLUMN FOLLOWING ADMINISTRATION —

1 TIME/DATE DISPENSED

,i _,,,1

- ..

ifilri- nc-_-_i_-2-r -t Kit

\\) ci \'1° -c- ergo

pltp 140 lea), 14°V

. :0

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fav

to ma

IODCO% 141 ++ laai

nocazIT 4,461—}0 tic4

osmiOv pew ./..,-.

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Loa , ,I 1

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l lip Pere --4 (A-19°' --7- L 7.4,1 SeTCre.- or( v' /1-

fiNty 9051)

pai vo

,

. .

....._

'U.S. GPO: 1990-454-110/95216

MEDCOM - 23630

DOD-037208

ACLU-RDI 1681 p.190

MCAT

MEM J. INJURY , BLESSUPE

PIL ■ • •.:1,Z I • MiC.15:: 0.11 r3 CH F:1,04

P..VVAIr IRAQ-It( C,CK ,ARaiERE

T.STE

WOUND , OLE 5208

NECk•SA Cr. UI ER?! BLESSuRE AU COO/s0 r-o5

BURN mot tin -----

AMPUT or:ON• amP,../1"..1TION

STRESS, TENSION

OTHER (SP.N,Y) . AU THE (.5,2t,ci led

5 t—tsi—d- riA/EL frism t F

7 0)

I

•

17:

F :MADE MOLE .'NOMINE ji 1E1 (PeN11.-11—

2 U .

i Oki; .• ELWIN:

r•r,ri4

4. LEVEL OF CONSCIOUSNESS,

NO/EAU DE CONSCIENCE

TiME NEURE

6

MORPHINE :MORPHINE I DOSE /DOSE

NONHC A ' SFS /Our ••

.2. TOURNIQUET !GARROT

"RI/NON YES / OUI

PAIN RESPONSE R:PONSE 4 LA liOULEUr. LHNIRE'WON5IVE SANS fiEPOA-;T--H

174 T/ME / 11E101£

9. g.,* C ■ ob

Uk

VIEIZIgT,M17,°07:51421W-Em426,.11%;;IMZE,101,`, TWark-4

(c_c)

(3e 13-7 /F'?.., list:- v P 97 e4-

lIME

S . •

ID grpgaic?' TIME /11E000

DECEASED / DECEot 11. PROVIDER/ UNIT / OFFICIER M DICALE /UNITE

DO Form 13 DEC 31

8o, rt. fonn reNacer ortwovs ..d/hons of DO Tom, ,380 and OD torn 7340 (mix

which obsolete.

DATE/DATE (YYMMOC)

U.S. FICHE MEDICAL FIELD MEDICAL CARD E DE L'AVANT ETAES-UNIS

MEDCOM — 23631

ACLU-RDI 1681 p.191

22 23

Co I 0

26 27

9 a BA GROUND

19 20

21 24 25

s- 28 29

30

31

10. LENGTH OF SERVICE

ETS

11. FM13

43 44 45

53 54 55 56 157 58 .59 60 6

PREY ADMISSION

YEAR E2 63

21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO

73 74. 75 76 77 178 79 BO

24. CLINIC SVC - ADMITTING 26. MTF TRANSFERRED FROM

28. MTF OF INITIAL ADMISSION

109 110 111 112 113

8

114

9D 91

92

93 94

95 • DB 89

27. LOCATION OF OCCURRENCE

107 108 (BaWe Casualty Only)

.• i F LOCATION

8 Mate or Country

Code.)

ADMISSION AND CODING INFORMATION . 1

For use of this form. see AR 40-400; the proponent agency Is OTSG

REPORTING MTF

2

3

4

6

A

REGISTER NUMBER NAME (Last, First, Middle Initial) 4, PAY GRADE • 5. SEX

16

17- 18

D. 6. DA MISSION 8. RA E NIC RELIGION

ORGANIZATION (Active Duty Only) , 13. MARTIAL STATUS HOUR OF

46

ADMISSION

12. SOCIAL SECURITY NUMBER

14. FLYING STATUS

16. BENEFICIARY CATEGORY 18. ZIP CODE OF RESIDENCE

WARD

17. UNIT LOCATION (Mate or. Country Coda)

20. SOURCE OF ADMISSION/ AUTHORITY FOR

72 ADMISSION

le. TRAUMA

71

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

50 51 52

71 a 18. MOS

64 65 6

67 68 69 70

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

23. DATE OF DISPOSITION (Y YYYMMD D)

81 182183 I 34 se es 871I88 a.10 IC) 13

I 12

I 28. DATE THIS ADMISSION Y YY MMD

99 I

c.) _3 ( / s'd

100 I 101 1.102 103 104 I 105 I 106

20, DATE INITIAL ADMISSION (Y Y Y YA4./fD.D) 115 116 117 118 119 120 121' • 122

FOR LOCAL USE

R`703

44 (43

ADMITTING OFFICER (Signature, as required) SIGNATURE OF ADMITTING CLERK

DA FORM 2985, MAR 2000 EDMON OF MAR 89 IS OBSOLETE USAPA V1.00

MEDCOM - 23632

DOD-037210

ACLU-RDI 1681 p.192

z. iviir Locatk... I

IZ Admission

For use of this form, and Coding Information

see AR 40-400; the proponent agency is OTSG 3. Register Number Name (Last, First, MI)

\O 1 C,2,

4. Pay Grade

FGN

5. Sex

M

6. DoB (YYYYMMDD)

1976-08-19

7. Age at Admission

27Y

8. Race

X

9. Ethnicity

9

Religion

10. Length of Service ETS 11. FMP

20

12. Social SecurityNumber

Organization (Active Duty Only) 13. Marital Status Hour of Admission

10:35

Branch / Corps:





DIS

Prey. Admission

NO


Direct from ER

Ward:

ICW1

Name / Relationship of Emergency Addressee

Address of Emergency Addressee

Name and Lo • ' Facili • eb 1 1),,„ t Telephone Number of Emergency Addressee


TRF-OTH


2003-11-14


ABD - NEUROSURGERY


2003-11-14


2003-11-14

mp i rv,ei I !cc


Admission Diagnosis Narrative: L FACAIL HEMOTOMA, L SHOULD SHRAPNEL,R HIP SHRAPNEL



- Z.--

11111111.111111 11r Admitt

Automated Facsimile - DA FORM 2985, MAR 2000 MEDCOM - 236

DOD-037211

ACLU-RDI 1681 p.193

Automated Facsimile

INPATIENT TREATMENT RECORD COVER SHEET For use of this form, see AR 40-400, the proponent agency is OTSG

. Register Nbr .2. Name

)"c, - IA

3. Grade

FGN 1 Admission Remarks

;20. Type Case

4. Sex 5. Age M 27Y

I i 6. Race 17. Religi I

X I

8. LnthOfSvc 9. ETS

-I

10. PrevAdm

NO

11. FMP 12. SSN 99

13. Organization ..,----

14. Ward

ICW1

15. FlyStatus 17. Dept / Ben-- -

K78-PRISONER 0 WAR/INTER

18. BranchCorps 19. UIC / ZIP

DIS


Direct from ER

22. Hour Of Adm: 10:35

23. Clinic Service

24. Name/Relation of Emergency Addressee 25. Type Disp TRF-OTH

26. Date of Disp

2003-11-11

27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm:

2003-11-08

Admitting0fficer:

6( i -2-

30. Date !nit Adm

2003-11-08

32. Units Blood Components






SHRAP INJURY L CHEST

• "A 11 . 0 1 ..-1 9 Q616.0 T5 , '5 1 `615.0

15;clet 5


Absent Sick Days

0

Other Days

0

ConLv / Coop Care Days Supplemental Care

0 Bed Days

L-f Total Sick Days

v I


Absent Sick Days

0 Other Days

0 ConLv / Coop Care Days

0 Supplemental Care

0 Bed Days

If Total Sick Days

q Signature of Attend' • Officer Signature of PAD icer

Automated Facsimile - DA FORM

MEDCOM - 23634

DOD-037212

ACLU-RDI 1681 p.194

PHYSICAL EXAMINATIONEXAMINATION

MEDICAL RECORD ABBREVIATED MEDICAL RECORD

IRTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION ( Enkr dare of ad twerian,

e-i. &at) _TO-0 cry

sclt-i/191—e-e t' r(7 e .19 6 4P- ii(-1-7 ele 5 •

"Li gA)

7:49

I a- ?_s

Qv/ -71-9

PROGRESS ( Eater dart of dirrhorge and final diaynme

Ad&c-19-

-

'

ABRREWATED MEDICAL RECORD Stands.rd For Safi

GENERAL SERVICES AOMINis -r-r-,Ar.cm AND INTERAGENCY COMMIT-TEE ON MEDICAL RECORDS PRL1R (41 CF.. ..) 201-45.505 CCTCEER 1575 539-106

MEDCOM - 23635

LeA)rEreUt53

5IG 10ENTIFICATION O. ORGANIZATION

middle; /r ide; d•re; llorpir•l or medIcel !>•c lily) f typed or retur n r. P.'. i.i•f le rear. Arra, NCO ts-rcR NO. I WARD NO.

ACLU-RDI 1681 p.195


DATE NOTES

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Wct/sfic_ I*

STANDARD FORM 509 (REV. 5/1999) BAC:-

USAPA VI.0

MEDCOM - 23636

DOD-037214

ACLU-RDI 1681 p.196



DATE NOTES

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RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER (SSN or Other) LAST FIRST MI




PROGRESS NOTES Medical Record STANDARD FORM 509 (REV. 5/1999:

Prescribed by GSA/ICMR FPMR (41CFR) 101-11.203(b)(10:

USAPA V1.00 4-(

MEDCOM - 23637

DOD-037215

ACLU-RDI 1681 p.197

AUTHORIZED FOR LOCA

`MEDICAL RECORD I PROGRESS NOTES

DATE NOTES

raON 63 r--- .4_

--D 7 VSS V Oi C g-e__. 0 ,D a\irN of- 20)30 NC I C(Y-\ -4--, N .__-S 0 -(--•C - -

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0 c___erp aTelcf\c- -6(c,_, -2_

RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER ISSN or Dried LAST FIRST MI

DEPARTJSERYICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (For typed or written entrie4 gin: Name • int fiat, middle ID No Of SSN; Sex,- DM of Birtk; fiankffliffki

I REGISTER NIL WARD NO.


STANDARD FORM 509 MEV. 0/19051 Prescribed by GSABCAIR FPMR KIM) 101-11.203M110)

USAPAVIA

MEDCOM - 23638

DOD-037216

ACLU-RDI 1681 p.198

(See Instructions on Back of this Sheet) 558-103 NSN 7 540-01-075-3786

TRANSPORTATION TO HOSPITAL (Attach care enroute sheet)

I-1 PRIVATE VEHICLE H AMBULANCE

D OTHER (Specify)

DUTY STATION (City, State and ZIP Code)

CURRENT MEDS. (tetanus immun- HISTORY OBTAINED FROM ization and other data)

El PATIENT DOTHER (Specify)

ALLERGIES

HOME TELE. NO. (Inc. area cosiV--

DAY MONTH Y

0 ol L.) PATIENTS HOME ADDRESS OR

DATE TIME ARRIVAL

(CONTINUE ON SF 507, IF NEEDED SIGNATURE OF PROVIDER AND ID STAMP

INSTRUCTIONS TO PATIENT (Include medications o plans)

n•MTIC HIVU I IsEATMENT STANDARD FORM 558 (Rev. 6-82)

DOD-037217

CHIEF COMPLAINT(S) (Include symptom(s), dura t on)

VITAL SIGNS TIME

BP

PULSE

RESP.

TEMP.

NON-URGENT

EMERGENCY TODAY

72 HOURS ROUTINE

ASSESSMENT/DIAGNOSIS

DISPOSITION (Check all that apply)

HOME I 'FULL DUTY

QUARTERS

124 Hrs. I 148 His. 172 HI'S.

MODIFIED DUTY UNTIL: DAY I MONTH I YEAR

REFERRED TO (Indicate clinic)

ADMIT. TO HOSP. UNIT/SERVICE

CONDITION UPON RELEASE

IMPROVED I 'UNCHANGED

DETERIORATED

TIME OF RELEASE:

PATIENT'S IDENTIFICATION (Mechanical imprint) FOR WRITTEN ENTRIES GIVE: Name - last, first, middle; GSM; DOB, service status, name and relation of sponsor or next of kin. (IMPORTANT: LIST FACILITY HOLDING TREAT-MENT RECORD).

OF,

SEX

7A °)

AGE POSSIBLE THIRD PARTY PAVER?

0 YES n NO DESCRIBE (1) Slibjective data (Pertinent History); (21 Objective data TIME SEEN BY ROVIDER (Examination - include results of tests and x-rays); (3),Aisessment (Diagno-sis); (4) Plan (Treatment/Procedures - include medication given and follow-up

s and follow-up

MEDCOM - 23639

&q 9 e\( -51,9e

V")."

(--et

(It,/ (Pp s ke( (411.S

ge,K

ci\A-65). ca_kr.,L (9c946-.5

cin

EMERGENCY CARE AND Tr 'ATMENT (Medical Record)

TREATMENT FACILITY (Stamp) LOG NUMBER

ACLU-RDI 1681 p.199

SKIN AND WOUND ASSESSMENT MEDICAL RECORD PROGRESS NOTES

Admission Date: //--er"."-- () --'',' Diagnosis - '-----Z<.____,_.

/— eibp---"i2...y 1--): POD: C-X-- -ii;y-'

(See Braden Evaluation Table for Details) Braden Scale Evaluation .

Sensory No impairment 4 Perception Slightly limited 3

Very limited 2 Completed I

, Mobility No limitations 4

Slightly limited 3 Very limited 2 Completely immobile

Moisture Rarely moist 4 Occasionally moist 3 Moist . 2 Constantly moist 1

Nutrition Excellent 4 Adequate (Eats >50%) 3 Adequate (Rarely eats) 2 Very poor

Activity Walks frequently 4 Walks occasionally 3 Chairfast 2 Bedfast I

Friction and No apparent problem 3 Shear Potential problems 2

Problems I

Add the total score

Above 20 Low Risk Between 16 and 20 Medium Risk Between 11 and 15 High Risk Below 10 Very High Risk

Note: A Braden Scale Score of less than or equal

Total Score

to 15 indicates HIGH RISK –Requires immediate Ulcer prevention program.

Surgical wound (s): Yes No Location: Tubes:

Size: Drainage: Appearance:

Dressing change: Pressure Ulcer (s): Yes No Stage I, II, 1(1, IV (Circle the one that applies and

Location:

describe below)

Size: Wound character: Pint Moist Dry Granulation tissue Yellow slough

Odor Purulent discharge Eschar Exudates

Type of dressing change: Wet-to-dry Comfeel dressing . Carrasyn V-Gel Alginate

Physician notified consulted for wound debridement: CNS notified/consulted for Stage II and greater: Nutrition Referral: Yes No

Yes No Yes No

Physical Therapy Referral: Yes No Action Taken: Date & Time:


Patient's ldentification (For typed or written entries give: Name-last. first. middle:

Grade; rank; hospital or medical facilithy) PROGRESS NOTES

Medical Record

STANDARD FORM 509 sr

MEDCOM - 23640

DOD-037218

ACLU-RDI 1681 p.200

Documents

ec 1e-z1 · hr 7 13 ense d 15 kc7 date disp verify by initialing order date clerk/ nurse ' recurring medications, dose, frequency =1_0 ion -zvi i\j (-4 i fl d k val t(4,-) pc-3 "tg°